2004 Exam II Case 01
Chief Complaint
A 37-year-old male presenting with confusion and weakness.
History of Chief Complaint:
The patient was brought to the community hospital by his girlfriend 3 days ago. He was obtunded and unresponsive to all stimuli. Questioning the girlfriend revealed that the patient had been binge drinking all weekend. Upon arrival at the hospital, lumbar puncture revealed blood in the cerebrospinal fluid and CT demonstrated the presence of a “star-sign” and gyral effacement. The patient was stabilized and began responding to painful stimuli 12 hours after arrival. He awoke from his obtunded state 24 hours after arrival. A toxicology screen confirmed that the patient had been under the influence of alcohol and cocaine.
Medical History:
The patient has no traceable medical records for the past 15 years and due to his current status, his oral history is unreliable.
General Physical Examination:
This is a 37-year-old male who looks older than his stated age. Although conscious and responsive to painful stimuli, he does not contribute information spontaneously. He appears malnourished and his skin reveals needle marks indicative of drug use. Heart rate is regularly irregular and auscultation reveals wheezing at lung bases bilaterally. Auscultation of the abdomen reveals decreased bowel sounds and palpation indicates ileus in the left lower quadrant. The patient is afebrile and has a pulse of 74 beats per minute.
Neurologic Exam:
Mental Status: The patient is calm and quiet. He offers no information but will respond to questions on occasion. He engages in no spontaneous conversation. He displays very little spontaneous movement and can sit quietly for long periods of time. When pushed to respond, most of his responses are articulate but displayed confusion for his current situation.
Cranial Nerves: Visual acuity is difficult to test because the patient cannot stay focused on the instructions. Extraocular muscles are intact, but the eyes seem to rest to the left. His occasional vocalizations reveal that the facial muscles are intact, but close observation reveals that the right nasolabial fold is less pronounced than the left.
Motor: Strength testing reveals the following results. On the right: shoulder 5/5, elbow 4/5, wrist 4/5, hip 2/5, knee 1/5. On the left: strength is 5/5 in all muscles. DTRs on the right: upper extremity 2/4, knee and ankle are 4/4. On the left: 2/4 at all joints. The patient is continent for both bowel and bladder function.
Sensory: A patchy loss of two-point discrimination and vibratory sense is present on the right foot and ankle and there is a patchy distribution of analgesia on the right thigh and leg. Patient responds to all stimuli on the left lower extremity and both upper extremities.
Follow-up:
The patient remained in the hospital for 3 weeks and was discharged to a head trauma institute for 3 weeks after which he was released. He now reports for a follow-up visit with his girlfriend 3 weeks post release. He is a little more talkative today then he was in the hospital. His speech is clear and he is able to clearly recall the current events of the last week. He knows what county he is in and can recall the day, month and year. He can recall specific events that occurred during his hospital stay even though he was fairly non-communicative at the time they occurred. Strength testing shows strength to be 5/5 in the upper extremities bilaterally with deep tendon reflexes at 2/4. The right lower extremity has not improved in strength and the patient still uses the wheelchair he was given at discharge from the hospital. The patient’s girlfriend has noted that he has a hard time using his left hand. He was asked to demonstrate several tasks with his hands. He had no problem mimicking the use of common tools with his right arm, but the results with the left arm were interesting. When asked to show how he would use a hammer with his left hand, the patient raised his arm in the air and proceeded to make a succession of circular, waving motions with his arm. The patient demonstrated the same amount of difficulty when asked to show how he brushes his teeth and combs his hair with his left hand but had no problems with his right.
INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.
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Number: 01 The motor deficit expressed in this patient’s right lower extremity is best termed:
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Number: 02 The motor deficit expressed in this patient’s right lower extremity is most likely due to a lesion of the:
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Number: 03 The sensory loss present in this patient is most likely due to damage involving the:
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Number: 04 The motor deficit expressed in the patient’s left hand on follow-up is best termed:
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Number: 05 The motor deficit expressed in this patient’s left hand on follow-up is most likely due to a lesion of the:
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Number: 06 The resting position of the eyes reveals a mild:
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Number: 07 The loss of spontaneous activity present initially in this patient is best termed:
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Number: 08 The loss of spontaneous activity present initially in this patient is most likely due to damage involving the:
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Number: 09 Of the following locations in this patient the most likely location to find chromatolytic cell bodies would be:
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Number: 10 Of the following locations in this patient the most likely location to find degenerating axons would be:
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Number: 11 The best description of the temporal profile for the onset of this neurological disease would be:
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Number: 12 The best description for the distribution of the patients neurological disease would be:
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Number: 13 Of the following list, the most likely pathological process that accounts for the patient’s neurological disease would be:
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Number: 14 Imaging of this patient would most likely reveal vessel occlusion in the territory of the:
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