2005 Exam I Case 01

Chief Complaint:

A 56-year-old, right-handed female presents to the physician’s office today complaining of headaches, sharp burning pains on the right side of her face and strange sensations from the right side of her body

History of Chief Complaint:

Patient states that she has been having headaches on and off for about 10 months. She claims that recently the headaches have been unilateral (left side) and centered on the upper posterior cervical region.  Approximately 6 days ago, the patient noticed an occasional change in her voice and had difficulty swallowing dry food. Within the past 24 hours, these symptoms increased in frequency and duration until yesterday afternoon when the onset was also accompanied by a painful, burning pain on her right face.  These symptoms have not subsided. She complains of stumbling to avoid objects, and feels “off-balance” when walking.

Past Medical History:

She had a complete hysterectomy when she was 35-years-old.  She was diagnosed with hypertension and hyperlipidemia at the age of 43, but has been very lax on seeing her doctor for regular checkups.  She has not been on hormone replacement therapy.

Social History:

She is a restaurant reviewer and loves to travel.  She denies the use of illicit drugs, but admits to social alcohol use and a 20-pack-year history of smoking. She wears her seatbelt when she travels and all of her immunizations are up-to-date.  

General Physical Examination:

Vital Signs:   BP: 158/99       HR: 105        Temp: 98.6◦F       Resp: 16      Height:  5’4” Weight: 130lbs.  Patient is a well-groomed, pleasant female who appears her stated age.  Head is normocephalic and without evidence of trauma.  Skin is supple and moist. Neck is without evidence of lymphadeopathy.  A grade 2/6 carotid bruit is present on the left. Heart rate was elevated with regular rhythm. Chest is clear to auscultation without crackles, rhonchi or wheezing. 

Neurological Examination:

Mental Status:  The patient is alert and oriented to person, place and time.  Her speech is meaningful and her memory and knowledge are appropriate. She can follow multistep commands. 

Cranial Nerves:  Visual acuity was 20/20 in both eyes; on left lateral gaze, there was an oscillating motion of the eyes with a slow movement toward the midline and the fast movement outward to the left.  She complained of feeling dizzy during these eye movements and of seeing double.  Extraocular movements were full.  Ptosis of the left eyelid was present. Left pupil is 3mm, right pupil is 5mm, both are reactive to light and accommodation.  Numbness to pain was present on the left side of the face, with sparing around the mouth.  The left side of the face had decreased sweating. Facial expressions were full bilaterally. The corneal and gag reflexes were sluggish.  Hearing was intact to finger rub bilaterally. Hoarseness was noted, the uvula deviated to the right and there was insufficient elevation of the palate on the left. The tongue protruded midline and was without fasciculations. 

Motor System:  Strength is intact throughout upper and lower extremities. Deep tendon reflexes are normal and symmetric.  However, finger-to-nose and heel-to-shin testing was slightly abnormal in the left extremities.

Sensory Exam:  There is a loss of pain and temperature sensation present in the upper and lower right extremities.  Loss of pain and temperature were also absent on the left side of her face. Two-point discrimination, vibration and proprioception were intact in all areas of the body including the extremities and face.

Follow-up:

At examination one month later, the headaches have abated. Sensation to the right body and the burning pain on the right face also resolved. The only complaints that remained are a mild loss of sensation to pain to the left side of the face and a slight feeling of choking when eating solid foods.

Questions

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