Chief Complaint
A 79-year-old, right-handed retired business, executive was brought to his general practitioner's office by his son after suffering a momentary loss of consciousness followed by the development of double vision and a tremor in his left arm.
History of Chief Complaint
He complained of frequent dizzy periods over the last 5 days. The dizzy episodes were occasionally accompanied with diplopia. On the morning of admission, he had experienced a brief period of syncope upon arising from bed. After regaining consciousness he complained of a pronounced and persistent double vision.
Past Medical History
He had been married for 40 years; his wife had died 5 years earlier. He had been an executive for a large firm. After retirement he has been active socially and played sports.
His past medical history was positive for rheumatic fever at age 6. For the past 5 months he had been experiencing periods of dizziness and fatigue.
He had a 30-pack-year history of smoking, but quit completely 3 years before. He drank 2 to 3 ounces of alcohol socially per week.
His past medical history was positive for rheumatic fever at age 6. For the past 5 months he had been experiencing periods of dizziness and fatigue.
He had a 30-pack-year history of smoking, but quit completely 3 years before. He drank 2 to 3 ounces of alcohol socially per week.
General Physical Examination
He was alert and oriented, well nourished, and of average weight; he appeared his stated age. The patient frequently had to cover his right eye with his hand in order to move about the room.
Optic discs were clear with sharp borders. External auditory canals were patent. His neck was supple; there where no bruits over the carotid artery. His larynx and pharynx were non-reddened.
His chest was clear to auscultation and percussion; abdomen was soft without rigidity, tenderness, or organomegaly. Heart rate was irregularly irregular.
Peripheral pulses were intact; a pulse deficit was present, with the auscultated apical rate exceeding the radial pulse rate. Blood pressure was 135/93, temperature was 37°C, and respirations were 16/min. No cervical, axillary, or inguinal lymphadenopathy was present.
Optic discs were clear with sharp borders. External auditory canals were patent. His neck was supple; there where no bruits over the carotid artery. His larynx and pharynx were non-reddened.
His chest was clear to auscultation and percussion; abdomen was soft without rigidity, tenderness, or organomegaly. Heart rate was irregularly irregular.
Peripheral pulses were intact; a pulse deficit was present, with the auscultated apical rate exceeding the radial pulse rate. Blood pressure was 135/93, temperature was 37°C, and respirations were 16/min. No cervical, axillary, or inguinal lymphadenopathy was present.
Neurologic Examination
Mental Status. The patient was alert and oriented to time and place with memory and knowledge appropriate for his age. He was articulate in speech and had good comprehension of spoken and written language. He gave a comprehensive history.
Cranial Nerves. On forward gaze, with the lid forcibly elevated, the right eye had an external strabismus; on attempted left lateral gaze, the right eye drifted toward the midline. The right pupil was larger than the left.
The right pupil was unresponsive to light shined in either eye; the left pupil was responsive to direct and consensual light.
The right eyelid elevated 4 mm, whereas the left elevated 13 mm on forward gaze. With the right eyelid forcibly elevated, its visual field was full to confrontation. The visual field in the left eye was also full.
The patient noted diplopia on attempted vision into all fields of gaze. The diplopia was absent with the right eye covered and exacerbated when the right eyelid was fully elevated.
Hearing was normal in both ears. He had a full range of facial expressions. Jaw-jerk and corneal reflexes were normal; the palate was elevated on the midline; gag reflex was normal; and tongue protruded on the midline.
The right pupil was unresponsive to light shined in either eye; the left pupil was responsive to direct and consensual light.
The right eyelid elevated 4 mm, whereas the left elevated 13 mm on forward gaze. With the right eyelid forcibly elevated, its visual field was full to confrontation. The visual field in the left eye was also full.
The patient noted diplopia on attempted vision into all fields of gaze. The diplopia was absent with the right eye covered and exacerbated when the right eyelid was fully elevated.
Hearing was normal in both ears. He had a full range of facial expressions. Jaw-jerk and corneal reflexes were normal; the palate was elevated on the midline; gag reflex was normal; and tongue protruded on the midline.
Motor Exam. Strength was normal in all limbs; deep tendon reflexes were +2/5 on the right and +3/5 on the left. No Babinski response was present. A tremor of intent was present in the left arm. Finger-to-nose testing was normal on the right, but he was slightly off target when using the left upper limb. The left arm and hand displayed an occasional jerky movement that the patient could not suppress.
Sensory Exam. Pinprick and temperature sensation were normal throughout body and face; position sense and vibratory sensation on the left side of his body was diminished. This sensory loss was more noticeable in the upper than in the lower extremity.
☞ 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?
