1997 Exam I Case 05

Chief Complaint:

A 55 year old right-handed male presenting with right sided weakness.

History of Chief Complaint:

He had been treated for hypertension for 10 years. Three weeks ago while on a buisness trip, he was found on the floor of his hotel room, disoriented, not knowing what had happened. He was brought to the local medical facility for observation. He was stabilized and released 36 hours later. After returning from his trip, and 3 weeks post accident, he is brought in for examination.

Physical Exam:

Pateint is afebrile, blood pressure 140/90, heart rate is 82, respiratory rate is 18. Neck is supple and thyroid is not enlarged. There is a soft blowing bruit in the left carotid artery. Heart has a regular rythme without murmur. Lungs are clear to auscultation. Abdomen is soft and not tender without bruit.

Neurological Exam:

Mental Status: This is an awake, oriented, alert individual with a pronounced weakness on the right side of his body and dysarthria. He was well aware of his situation. He could comprehend written and spoken language, he could attempt writing with his left hand with reasonable results. Memory for recent and past events was intact. Speech was meaningful but words were slurred as if speaking with an object in his mouth.

Cranial Nerve Exam: He had complete visual field with a full range of eye movements. Pupils were symmetrical and responsive to light both direct and consensual. A mild vertical nystagmus was present during gaze in any direction. His hearing was normal in the left ear and slightly diminished in the right ear. He had normal range of facial expressions and they were appropriate. Corneal, gag, and jaw-jerk reflexes were intact. Palate elevated on the midline, the tongue deviated to the left when protruded and had pronounced fasciculations. Pinprick, thermal sense and discriminative touch were normal on his face.

Motor Exam: His strength was diminished in the upper and lower extremities on the right. Deep tendon reflexes were +2/4 on the left throughout both extremities and +4/4 in the wrist and forearm on the right and +3/4 in the knee on the right. Rapid movements could not be tested on the right but were normal on the left. No fasciculations were evident in any extremity. The plantar reflexes were extensor on the right and flexor on the left.

Sensory Exam: He was responsive to pin-prick throughout his body. Two-point discriminative touch and vibratory sense were diminished over the right side of his body but were normal on the left.

Questions

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

Question 01:

The deviation of the tongue expresed in this patient is most likely due to a lesion of the:

a) nucleus ambiguus

b) hypoglossal nucleus or its radiations

c) glossopharyngeal nerve root

d) facial nucleus or nerve root

e) hypoglossal nerve

ANSWER

Question 02:

The alteration in deep tendon reflexes of this patient's upper and lower extremities, is most likely due to damage of the:

a) pyramidal tract

b) inferior cerebellar peduncle

c) pontine corticospinal tract

d) nucleus ventroposterior lateralis

e) lateral corticospinal tract

ANSWER

Question 03:

The extensor response in the right foot is indicative of damage involving the:

a) rubrospinal tract

b) corticospinal tract

c) ventral horn

d) vestibulospinal tract

e) peripheral nerve

ANSWER

Question 04:

The loss of discriminative touch in this patient most likely results from damaage to the:

a) dorsal root ganglion

b) dorsal horns

c) dorsal columns

d) dorsal column nuclei

e) medial lemniscus

ANSWER

Question 05:

The vertical nystagmus expressed in this patient is most likely due to damage of the:

a) vestibular nerve

b) vestibular nuclei

c) corticospinal tract

d) medial longitudinal fasciculus

e) inferior cerebellar peduncle

ANSWER

Question 06:

Chromatolytic cells related to this lesion could most likely be found in:

a) facial nucleus

b) nucleus ambiguus

c) accessory motor nucleus

d) hypoglossal nucleus

e) medial motor nucleus

ANSWER

Question 07:

Degenerating axons related to this vascular accident would most likely be found in the:

a) corticospinal tract above the medulla

b) corticospinal tract above the pons

c) medial lemniscus above the pons

d) dorsal columns of the cervical cord

e) anterolateral tract above the medulla

ANSWER

Question 08:

The distribution of this lesion is best described as:

a) focal and on the right

b) focal and on the left

c) bilateral and symetrical

d) bilateral and asymmetrical

ANSWER

Question 09:

The location of the lesion along the neuraxis can best described as:

a) rostral lateral pons

b) caudal lateral pons

c) caudal medial medulla

d) rostral medial medulla

e) cervical spinal cord

ANSWER

Number:

The vascular supply most likely involved in this patient's lesion is:

a) anterior spinal artery

b) posterior inferior cerebellar artery

c) superior cerebellar artery

d) posterior spinal artery

e) great medullary artery

ANSWER