1997 Exam I Case 01
Chief Complaint:
This is a 53-year-old woman who is presenting with a post-stroke movement disorder
History:
She suffered a cerebrovascular accident five years prior to the current examination. The immediate result of the stroke was a weakness in the right extremities characterized by reduced strength and elevated deep tendon reflexes about the elbow, wrist, knee and ankle. She also demonstrated the presence of a Babinski sign on the right. As the weakness remitted over the next 3 months post-stroke, a movement disorder emerged. This disorder consisted of forcible, uncontrolled flinging motions of her arm and leg on the right. She has been placed on a strong neuroleptic compound to control the excessive movement. This has resulted in a fine tremor emerging in her left arm and leg. She is now presenting for a check-up.
Physical Exam:
This is a thin woman, fatigued and exhausted, who appears older than her stated age.
Neurologic Exam:
MENTAL STATUS: She is awake and oriented to time, place and person. Speech and memory are intact. She can follow two and three step commands with her left arm, but the excessive movement of the right extremity precludes its use. She admits to feelings of exhaustion, depression and desperation.
CRANIAL NERVE EXAM: She has a full range of eye movements and pupillary reflexes are intact to direct and consensual light. Her visual fields are full to confrontation. Immediately post-stroke, she was unable to see objects in her right visual field starting on the midline and extending to the periphery of the field. There was no macular sparing detectable at this time. This visual field defect slowly resolved over the first 6 months post-stroke. She responds to pinprick and light touch throughout her face. Corneal and gag reflexes are intact. Facial expressions are symmetric, palate elevates on the midline and tongue protrudes on the midline.
MOTOR EXAM: Strength and deep tendon reflexes are intact in the left extremities, but cannot be examined in the right extremities due to the excessive motion. Her right arm and leg are constantly in motion. The motions consist of periodic flinging movements embedded on a background of constant jerky movements. The excessive motion makes standing and walking difficult. The left extremities express a tremor that amelurates during purposeful motion and returns during rest. This tremor first presented 6 months after she began treatment with a neuroleptic agent for control of the flinging motions in the right extremity.
SENSORY EXAM: She responds to pinprick throughout her body. Proprioceptive and discriminative sense are intact on the left side, but cannot be tested on the right due to the excessive motion
Questions
INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.
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Number: 01 The initial weakness (5 years ago) expressed in this patient is best described as:
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Number: 02 The initial weakness (5 years ago) expressed in this patient most likely arises from a lesion of the:
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Number: 03 The emergent movement disorder expressed in the right extremities of this patient is best described as:
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Number: 04 The emergent movement disorder expressed in the right extremities of this patient most likely results from a lesion involving the:
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Number: 05 The visual field defect present in this patient immediately post-stroke is best described as:
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Number: 06 The visual field defect present in this patient immediately post-stroke is most likely due to a lesion of the:
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Number: 07 The drug-induced movement disorder expressed in this patient's left arm is best described as:
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Number: 08 The expression of the movement disorder in the left extremities of this patient is most likely due to the thalamic-level reduction in the release of the neurotransmitter:
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Number: 09 In this patient, a likely place to find chromatolytic neurons would be the:
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Number: 10 In this patient, a likely place to find degenerating axons would be the:
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Number: 11
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