Chief Complaint
This 65-year-old, right-handed man was brought to the emergency room early in the morning by his family. They complained that he was confused and had difficulty communicating with them. He had been that way since shortly after he awoke that morning.
History of Chief Complaint
He was in good health until 7 years before, when he was diagnosed as having hypertension. One year later he was admitted to the community hospital, the day after he experienced a brief episode of quadriparesis, blurred vision, and nausea.
At that time Doppler studies of the carotids were normal, as were lumbar puncture, electroencephalogram, and a computed tomographic (CT) scan. Diabetes was detected and he was given a regimen of insulin and discharged. During the next 4 years, no known transient ischemic episodes occurred.
The day prior to this most current admission, he had complained of intermittent weakness in his right hand.
At that time Doppler studies of the carotids were normal, as were lumbar puncture, electroencephalogram, and a computed tomographic (CT) scan. Diabetes was detected and he was given a regimen of insulin and discharged. During the next 4 years, no known transient ischemic episodes occurred.
The day prior to this most current admission, he had complained of intermittent weakness in his right hand.
Family History
At the time of admission he was married, retired from military service, and had two children, both of whom are married. His father had had hypertension and died at 55 of coronary artery disease; his mother was still living.
General Physical Examination
He was a well-hydrated, well-nourished man in no acute distress who appeared the stated age. Funduscopic examination revealed arterial-venous nicking without hemorrhage or papilledema.
His heartbeat was regular without murmurs or gallops. Blood pressure was 180/100. Respiration and pulse were normal. Lungs were clear to auscultation. Abdomen was soft without masses.
Skin was of good texture and temperature. Several small areas of active keratosis on the right posterior scalp were evident.
His heartbeat was regular without murmurs or gallops. Blood pressure was 180/100. Respiration and pulse were normal. Lungs were clear to auscultation. Abdomen was soft without masses.
Skin was of good texture and temperature. Several small areas of active keratosis on the right posterior scalp were evident.
Neurologic Examination
Mental Status. He was disoriented with respect to time, place, and personal information, relying on his family members to supply much of the history.
He had impaired recent memory and fund of knowledge. (He said Kennedy was president.) He confused the left and right sides of his body.
A mild sensory neglect, detectable with extinction testing, was apparent on his right side. His speech was poorly articulated and perseverative, and he used word substitutions and mispronounced words frequently; however, he had normal repetition of speech.
He had impaired recent memory and fund of knowledge. (He said Kennedy was president.) He confused the left and right sides of his body.
A mild sensory neglect, detectable with extinction testing, was apparent on his right side. His speech was poorly articulated and perseverative, and he used word substitutions and mispronounced words frequently; however, he had normal repetition of speech.
Cranial Nerves. He had a full range of eye movements. There was a right homonymous hemianopsia. Pupils were symmetric and bilaterally responsive to light both direct mad consensual.
Hearing was normal in both ears. Corneal, jaw-jerk, and gag reflexes were intact. His face was asymmetric on spontaneous emotional expression (e.g., smiling), but not on voluntary movement (right "emotional" facial paralysis). Discriminative touch was intact across his face, bilaterally.
The uvula was elevated on the midline; the tongue protruded on the midline. Shoulder shrug was symmetric.
Hearing was normal in both ears. Corneal, jaw-jerk, and gag reflexes were intact. His face was asymmetric on spontaneous emotional expression (e.g., smiling), but not on voluntary movement (right "emotional" facial paralysis). Discriminative touch was intact across his face, bilaterally.
The uvula was elevated on the midline; the tongue protruded on the midline. Shoulder shrug was symmetric.
Motor Systems. Strength in the limbs was +5/5 in the left arm and leg and +3/5 in the right arm and +4/5 in the right leg. Deep tendon reflexes were elevated in the right arm more than the right leg; they were physiologic on the left. A Babinski sign was noted on the right.
Sensory Exam. Pain, light touch, and vibration sense were normal, but discriminative touch and proprioception were impaired in the right hand.
Follow-up
The patient remained in the hospital for five days, during which he some of the confusion cleared and he no longer demonstrated any signs of the neglect syndrome.
He was discharged to physical and occupational therapy for assistance with basic functions of living.
Re-examination at six months post-discharge finds a persistent right homonymous hemianopsia and mild right-sided weakness with slightly elevated deep tendon reflexes, but normal facial symmetry on emotional stimuli.
He was discharged to physical and occupational therapy for assistance with basic functions of living.
Re-examination at six months post-discharge finds a persistent right homonymous hemianopsia and mild right-sided weakness with slightly elevated deep tendon reflexes, but normal facial symmetry on emotional stimuli.
☞ 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?
