A 59-year-old man with headaches, double vision, dizziness, and ataxia.
Chief Complaint
A 59-year-old, right-handed male was admitted to the hospital with a chief complaint of occipital headaches of 4 days duration.
History of Chief Complaint
Three days prior to admission, the patient noted a sudden onset of diplopia on forward gaze and a sensation of dizziness. These complaints resolved within twenty-four hours. He experienced several episodes of dizziness and diplopia over the next 24 hours. One day prior to admission he noted a relatively sudden onset of dizziness, diploia and clumsiness in the right hand. These complaints have persisted since that time.
Medical History
The patient had been under treatment for hypertension for 6 years duration with blood pressures in the range of 180/110.
General Physical Examination
The patient was alert, oriented, and cooperative; he was a well-nourished man of medium height who appeared his stated age. Funduscopic examination revealed clear optic disc with sharp borders. The external auditory canal was patent and uninflamed.
Pharynx and larynx were non-reddened. A grade II/W bruit was present over the right carotid artery. His blood pressure was elevated (192/96). Peripheral pulses were intact at the ankle and wrist. Respirations were normal.
His chest was clear to auscultation: skin was warm and of normal texture; abdomen was soft with no tenderness, lumps, or masses. No edema was present in the extremities; no lymphadenopathy was present in the cervical or inguinal areas.
Neurologic Examination
Mental Status. The patient was awake and oriented with respect to person, place, and time. Memory was appropriate for his age. Speech was articulate and meaningful and he could follow three and four-step commands.
Cranial Nerves. Extraocular movements were full, but tine patient complained of diplopia made worse by lateral gaze to the left. Nystagmus was present on left lateral gaze. The right pupil measured 3 mm, the left was 5 mm, but both responded to light and accommodation.
Ptosis of the right eyelid and decreased sweating on the right side of the face (anhidrosis) were also present. Hearing was diminished in both ears to high frequencies. He admits to a feel of dizziness that he describes as the world moving around him. Pain, but not touch sensation, was decreased on the right side of the face with the exception of some sparing around the lips and nasal region.
The right corneal reflex was diminished. Facial expressions were full and symmetric. The uvula deviated to tile left, and there was deficient elevation of the right side of the palate. There was also a suggestion of hoarseness.
Motor System. Strength was intact throughout the body; deep tendon reflexes were intact and symmetric. An ataxia was evident in the right upper extremity on finger-tapping, hand-patting, and finger-to-nose tests. A side-to-side intention tremor was present. Ataxia was also present in the right lower extremity, on heel-to-shin and tibia-tapping tests.
Sensory Exam. He had a mild analgesia to pinprick on the left side of the body, the left "'arm, and the left leg. Position, vibration, and touch modalities were intact throughout the entire body.
☞ QUESTIONS
1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
4. Are any changes in sensory functions detectable?
5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?
