2004 Exam II Case 04
Chief Complaint:
71-year-old right-handed woman with rapid onset of slurred speech and weakness.
History Of Chief Complaint:
The patient had been well until 1 month previous when she fell and fractured her left wrist, which is currently in a cast. When current symptoms began she had been toweling herself off after going wading at the lake at her summer home. She felt her left side go weak and she had difficulty holding the towel with her left hand. Her balance became unsteady and stumbling, she fell to the ground. Her husband stated that he witnessed the fall and tried to help her up but she was unable to support her weight with her left leg. He noticed that her speech was slurred and hard to understand. She was unable to focus her eyes on his face when he spoke to her. Although she denied that anything had happened, he immediately called for help; they arrived at the ED approximately 40 minutes later.
Medical History:
She has a significant history of hyperlipidemia and hypertension which are partially controlled with medication. 2 years ago she underwent a right carotid endarterectomy. She had a 30 pack year history but denied alcohol use.
Physical Exam:
Exam reveals a well nourished, well hydrated female who appears her stated age. She was alert and oriented and was appropriately anxious as to her current condition. Her neck was supple, thyroid non-tender and without nodularity. There were bruits auscultated over the carotids bilaterally. Blood pressure was 142/96. Heart rate was 94 and regular with no murmurs, rubs, or gallops noted. Breath sounds were clear bilaterally and she did not appear to be in any respiratory distress. Abdomen was non-tender and bowel sounds were noted. Limbs were well perfused and capillary refill times were less than 1 second.
NEUROLOGICAL EXAM:
MENTAL STATUS: She was alert and oriented to time and place though was easily distracted and appeared anxious. She was able to speak fluently though her speech was slurred but meaningful. Comprehension, repetition, and naming abilities were intact. She was able to recognize family members and medical personnel as they entered the room but she exhibited a dense lack of awareness with respect to objects or stimuli on her left side. Her left arm was in a sling and when it was shown to her, she identified it as belonging to the examiner; however she claimed to have two arms, a right and a left.
CRANIAL NERVES: Optic discs were flat. She had a complete loss of vision in the left visual field for which she was unaware. Pupils were equal and reactive to light. There was no ptosis and both eyes could close tightly. She had a conjugate rightward gaze deviation and she could not voluntarily look past midline to the left. There was decreased sensation to pinprick and 2 point discrimination on the left side of her face. The left corner of her lip was closed but did not move when she attempted speech. Her attempts to smile or grimace were asymmetric. Her tongue protruded and uvula elevated on the midline.
MOTOR: She had normal tone and full strength in the right arm and leg. She was unable to make voluntary movements with the left arm and leg, although occasionally the left leg spontaneously stiffened in extension. Pinching the skin of the extremity could enhance these extensor motions. Deep tendon reflexes were 2/4 throughout on the right and absent on the left. Plantar response was physiologic on the right and extensor on the left.
SENSORY: Sensation to touch, pinprick, and proprioception was intact on the right and non-testable on the left since she denied the feeling of any contact on that side.
FOLLOW-UP:
Examination at 2 months after discharge finds her strength moderately improved with testing at 2/5 at the shoulder, elbow and wrist and 4/5 at the hip, knee, and ankle on the left. Deep tendon reflexes are 3+/4 on the left and plantar response remains extensor. Voluntary movement of these limbs are still absent and she requires assistance with some daily activities. Her awareness of the left extremities has improved somewhat and a patchy sensory loss for touch is now detectable about her face and hand. Extinction testing revealed blunted awareness of touch on the left. Although much of her visual deficit has persisted, she now has slight visual recognition in the inferior visual field more so than the superior.
Questions
INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.
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Number: 01 On initial clinical presentation, the left visual field deficit is best described as a:
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Number: 02 On follow-up, the left visual field deficit is best described as a:
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Number: 03 The defect in eye movements is best described as:
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Number: 04 The deficit in movement of her face is most likely due to a ____________ lesion of the____________ motor system.
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Number: 05 The speech deficit is best termed a:
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Number: 06 The movement of her left extremities in response to noxious stimuli are best termed:
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Number: 07 Her left-side unawareness is best termed a:
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Number: 08 Of the following locations in this patient, the most likely location to find chromatolytic cell bodies would be:
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Number: 09 Of the following locations in this patient the most likely location to find degenerating axons would be:
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Number: 10 The best description of the temporal profile for the onset of this neurological disease would be:
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Number: 11 The best description for the distribution of the patients neurological disease would be:
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Number: 12 Of the following list, the most likely pathological process that accounts for the patient’s neurological disease would be:
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Number: 13 On imaging, occlusion would most likely be present in the vascular territory of the:
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