1997 Exam I Case 07

Chief Complaint:

A 69 year old right-handed male complaining of dysarthria, weakness and difficulty walking, clumsy right hand and decreased sensory feelings.

History of Chief Complaint:

For two days prior to admission he had experienced severe occipital headaches. At 8:30 PM on the evening prior to admission he experienced clonic movements in his left arm. He awoke the next morning unable to get out of bed due to a weakness in his left arm and leg. During the morning of his day of admission, he developed dysarthria and an opthalmoplegia. He has remained stable over the past 2 days of his hospital stay.

Medical History:

He has a long standing history of hypertension for which he is currently taking atenolol and captopril. He was diagnosed with insulin-dependent diabetes five years ago. He has a 35-pack-year history of smoking non-filter cigarettes and has not quit to date. For the past two years he has been treated for angina pectoralis. He also complained of a cold feeling and occasional sharp pains emanating from his feet and ankles.

Physical Exam:

He is an awake and oriented male, appearing slightly older than his stated age. His blood pressure is 160/100 mm Hg., pulse is 19 beats per minute and respirations are 16 per minute. He is 6'3" and weighs 215 lbs. Bilateral carotid bruits are present. Peripheral pulses are present at the left wrist and trace at the right wrist. Peripheral pulses were absent at the ankles. He denies dysphagia, hiccups, nausea or vomitting.

Neurologic Exam:

Mental status: He is awake and oriented to person, place and time. His speech is dysarthric but meaning full. He could not say the phrase "puh-tuh-kuh" rapidly, having to form each syllable separately.

Cranial nerves: His visual fields are full to confrontation and pupils are responsive to light bilaterally. He has a full range of conjugate eye movements vertically; on the horizontal axis his eyes can move into the left hemifield volitionally but not into the right hemifield. Passive motion of his head to the left results in the conjugate movement of his eyes into the right visual hemifield. Accommodation movements are intact bilaterally. Sensation throughout his face is intact and he has a full range of facial expressions. Hearing is intact to finger rub bilaterally. Power in the sternocleidomastoid and trapezius muscles is intact. Gag, corneal, and jaw-jerk reflexes are intact.

Motor exam: Power in the extremity muscles is as follows: grip 5/5 right, 2/5 left; elbow flexors and extensors 5/5 right, 3/5 left; arm elevators and depressors 5/5 right and 4/5 left; knee flexors and extensors 5/5 right and 3/5 left; ankle dorsi- and plantar flexors 5/5 right and 2/5 left. Past pointing was present on finger-to-nose and heel-to-shin testing bilaterally. Rapid alternating movements with the hand were decomposed on the right and untestable due to weakness on the left. He could not attempt ambulation due to the weakness in the left leg and the uncoordinated motions of the right leg so gait analysis was prevented. Reflexes: Deep tendon reflexes are as follows: brachioradialis 2 on the right and 4 on the left; triceps 2 on the right and 3 on the left; gastrocnemius 2 on right and 4 on left; quadraceps 2 on the right and 3 on the left.

Sensory exam: Position sense and two-point discrimination are present on the right side of his body and right extremities except for his right foot and greatly diminished on his left body and left extremities. His feet and ankles lacked all position sense, vibratory sense and two-point discrimination bilaterally. Sensation to pin prick is intact throughout his body.

Follow Up:

Neurologic examination 2 months post stroke finds his power in the left in almost normal and that the right extremities have normal motion. Dysmetria is still detectable in the extremities on the left. The sensation is intact except at the ankles bilaterally.

Questions

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

Question 01:

The dysarthria expressed in this patient is most liekly due to a lesion of the:

a) Nucleus ambiguus

b) Dorsal motor nucleus

c) Corticonuclear fibers

d) Transverse pontine fibers

e) Vagus nerve

ANSWER

Question 02:

The ophthalmoplegia expressed in this patient is best described as an:

a) Abducens palsy

b) Internuclear ophthalmoplegia

c) Lateral gaze palsy

d) Lateral nystagmus

e) Retropulsion

ANSWER

Question 03:

a) Abducens palsy

b) Abducens nucleus

c) Paramedian pontine reticular formation

d) Medial longitudinal fasciculus

e) Pontine nuclei

ANSWER

Question 04:

In this patinet the Doll's Head Reflex would be considered:

a) present

b) absent

ANSWER

Question 05:

The loss of power in this patient is most likely the result of a lesion of the:

a) Middle cerebellar peduncle

b) Inferior cerebellar peduncle

c) Transverse pontine fibers

d) Corticospinal tract

e) Pontine nuclei

ANSWER

Question 06:

The loss of power expressed in this patient's extremities is best described as:

a) Spastic paralysis

b) Flaccid paralysis

c) Cerebellar ataxia

d) Sensory ataxia

e) Akinesia

ANSWER

Question 07:

The movement disorder expressed ipsilateral to the lesion in this patient most likely results from a lesion of the:

a) Inferior cerebellar peduncle

b) Transverse pontine fibers

c) Corticospinal tract

d) Pontine nuclei

e) Medial longitudinal fasciculus

ANSWER

Question 08:

The movement disorder expressed contralateral to the lesion in this patient most likely results from a lesion of the:

a) Inferior cerebellar peduncle

b) Transverse pontine fibers

c) Corticospinal tract

d) Pontine nuclei

e) Medical lemniscus

ANSWER

Question 09:

The loss of position sense in the extremities of this patient with the exception of the feet is most likely due to a lesion of the:

a) Anterolateral system

b) Spinocerebellar tracts

c) Medial lemniscus

d) Dorsal column nuclei

e) Peripheral nerves

ANSWER

Question 10:

The loss of position sense in the feet of this patient is most likely due to a lesion of the:

a) Anterolateral system

b) Spinocerebellar tracts

c) Medial lemniscus

d) Dorsal column nuclei

e) Peripheral nerves

ANSWER

Question 11:

In this patient, chomatolytic cell bodies will most likely be present in the:

a) Nucleus ambiguus

b) Dorsal column nuclei

c) Dorsal horns

d) Dorsal root ganglia

e) Ventral horns

ANSWER

Question 12:

In this patient, degenerating axons will most likely be present in the:

a) Anterolateral tract

b) Internal capsule

c) Spinocerebellar tracts

d) Inferior cerebellar peduncle

e) Middle cerebellar peduncle

ANSWER

Question 13:

The most likely location for this lesion on the neuaxis is:

a) Rostrolateral pons

b) Rostromedial pons

c) Caudolateral pons

d) Caudomedial pons

e) Rostromedial medulla

ANSWER

Question 14:

The best description of the distribution of this lesion is:

a) Focal and on the right

b) Focal and on the left

c) Multifocal

d) Diffuse

ANSWER

Question 15:

The best description of the temporal profile of this lesion is:

a) Acute and stable

b) Acute and progressive

c) Chronic and stable

d) Chronic and progressive

ANSWER

Question 16:

The artery most likely involved in this patient's lesion is the:

a) Anterolateral branches of the basilar

b) Anterior inferior cerebellar artery

c) Posterior inferior cerebellar artery

d) Anteromedial branches of the vertebral artery

e) Anterior spinal branch of the vertebral artery

ANSWER