2005 Exam I Case 04

Chief Complaint:
A 74-year-old, left-handed female was brought to the emergency room by her husband who states that his wife is walking funny.   

History of Chief Complaint:
The patient is an unreliable historian due to early stages of Alzheimer disease; her husband answers questions for her. She had been complaining the past few days of headaches and intermittent weakness and upon waking this morning, he noticed that she was unsteady when he helped her to the bathroom.  While eating breakfast this morning he noticed she was clumsy and she was drooling out of the left side of her mouth.  He was unsure if her behavior was due to her Alzheimer’s progressing, so he decided to bring her in. 

Medical History:
Diagnosed with Alzheimer’s at 66, hypertension

Medications:
Aricept for Alzheimer’s, Atenolol for hypertension (husband admits to increasing difficulty getting his wife to take pills, so she has not taken any in a few weeks)

Family History:
Her father died of complications due to Alzheimer’s disease at 78 and her mother of a heart attack at 57.  Her brother died at 22 in a motor vehicle accident.  She has one sister, age 62, who has hypertension, arteriosclerosis and is beginning to show changes in cognitive ability. 

General Physical Examination:
Patient is alert, friendly, but slightly confused, woman appearing older than stated age. The left corner of her mouth did not elevate with smiling.  Her left eye appeared reddened.  Her blood pressure was 178/89, pulse 80, temp 98.7, respiratory rate 15.  Peripheral pulses were intact bilaterally in both upper and lower extremity.  Eyes were clear.  Chest was clear to auscultation.  Bruit was heard over carotid arteries bilaterally.  Abdomen was soft with no signs of tenderness or masses. 

Neurological Examination:

Mental Status:   Patient is oriented to person, but not time or place.  Memory was patchy and language was slightly slurred but comprehendible, however, not always relevant. Pt can follow simple commands. 

Cranial Nerves:    Patient had volitional conjugate vision vertically and to the right, but was impaired to the left.  Eyes did move to the left with a doll’s head maneuver.  Pupils were equal and reactive to light. Hearing was intact bilaterally.  Gag reflex was intact and the palate elevated symmetrically. Her mouth drooped on the left which was more pronounced with smiling.  Eyebrows were asymmetrical when raised, the right higher than the left and her left eyelashes were visible when she attempted to close her eyes tightly.

Motor System:  Deep tendon reflexes were 3/4 in the right upper extremity, 4/4 in the right lower extremity, and 2/4 in both the left upper extremity and left lower extremity.  Strength was diminished on the entire right side.  Past pointing was present on the left, as was an irregular heel to shin test. 

Sensory Exam:   Pain and temperature appeared to be intact but patient became agitated with the introduction of pin prick stimuli.  Vibratory sense was intact bilaterally. 

Follow-up:
Eight weeks later, patient is no longer experiencing impairment on looking left.  Her husband states that she still has some residual problems bringing a fork to her mouth.  Her strength is still slightly diminished on the right.  

Questions

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