1997 Exam I Case 02

Chief Complaint: A 63 year old right handed female complaining of sudden onset of dysarthric speech, diplopia, clumsy hand movements and difficulty walking.           

History of Chief Complaint:  With the exception of mild hypertension she had been in good health up until this event. She experienced the sudden onset of dysarthric speech at 5:00 PM on the day before admission while preparing a meal.  At this time she also noticed a slight blurring of her vision when she looked to the left.  Later, around 6:30 PM, while trying to eat the meal she noted a clumsiness in the movements of her right hand and the blurring on left gaze became worse.  She could not say with certainty whether the clumsiness was present earlier or not.           

Medical History:  She experienced rheumatic fever at age 12. Diagnosed with mild hypertension 10 years prior to admission, control has been managed with diet and exercise.  Within the 10 days prior to admission she experienced the onset of diffuse arthralgias and fatigue.          

Surgical History:  None          

Allergies:  None           

Medications:  She used oral contraceptives until menopause at age 48.  She had not used any estrogen replacement therapy to date.           

Physical Exam:  This is an awake, oriented 63 year old post-menopausal woman who looks approximately her stated age. Her blood pressure is 220/110 mmHg, heart rate is 62 beats per minute, and a loud blowing systolic murmur is present. Respirations are 16 per minute.  Peripheral pulses are intact at the ankles and wrists.  She is 5'5" and weighs 129 lbs. Bilateral carotid bruits are present.  Lungs are clear to auscultation and percussion, abdomen is soft to palpation with no tenderness.  No lymphadenopathy is present.  She denies any dysphagia or dsypnea.          

Neurologic Exam:           

Mental status:  She is awake and oriented to person, place, and time.  She is dysarthric but her speech is fluent and meaningful.  Her fund of knowledge and memory are intact.  She can follow three step commands with both hands.          

Cranial nerves:  Visual fields are full to confrontation and pupils are reactive to light.  Extraoccular movements are intact on the vertical axis.  She can move her eyes volitionally to the right, on left lateral gaze the left eye fails to abduct.  She denies diplopia with the eyes at rest and admits to diplopia that begins on attempted left lateral gaze and worsens as the left lateral gaze is increased.  Convergence on accommodation is present bilaterally.  She responds to pinprick and light touch throughout her face.  Corneal and gag reflexes are intact. Facial expressions are asymmetric.  The right corner of the mouth does not move on attempted speech, smiling or grimace.  There is no drooping of the lips.  Both eyes close tightly and her forehead wrinkles symmetrically on upward vertical gaze.  Power in the sternocleidomastoids and trapezius muscles is intact.  Her uvula elevates on the midline and her tongue protrudes on the midline.          

Motor exam:  Her power is 5/5, symmetrical and intact throughout her body except for the abductors of the fingers on the right which are 4/5.  Dysmetria is present on finger-to-nose and heel-to-shin testing on the right extremities.  Rapid alternating movements of the right hand were slow and irregular.

Reflexes:  Deep tendon reflexes are within normal limits throughout her four extremities.

Sensory:  The sensory exam is within normal limits throughout her torso and extremities.

Questions

INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.