Case History #41

Date of Admission: 10-20-1978

HISTORY OF PRESENT ILLNESS:

This 85-year-old right-handed black female was admitted to the hospital because of confusion and disorientation.  The patient was confined to a wheelchair but was doing well in her own apartment and taking care of her own needs until the day of admission.  She was seen the day prior to admission by her daughter and was in her usual state of health.  On the day of admission, she was found sitting in her wheelchair, disoriented and confused, with her clothes laid out, but still not dressed.  She was brought to the hospital emergency room and was unable to communicate with the emergency room staff.  For that reason she was admitted to the hospital for neurologic evaluation. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  The patient was awake and alert.  She was extremely cooperative and pleasant.  She smiled and responded to questions with a generous amount of fluent speech, which was totally incomprehensible.  The patient did not comprehend anything that was said to her and therefore could not follow any commands whatsoever.  This was felt to be strictly related to impairment of comprehension rather than any tendency toward lack of cooperation.  Likewise, she was unable to repeat even the simplest of test phrases or words.  The speech that she produced made no sense in terms of the context of conversation or the examination.  Further testing of higher intellectual functions was impossible.

Cranial Nerves:  Intact.

Motor System:  There were no areas of focal muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal, although the patient could not cooperate for formal strength testing. 

Reflexes:  Deep tendon reflexes were equal and symmetric in all 4 limbs.  Plantar reflexes were flexor bilaterally. 

Sensory System:  The patient appeared to perceive pain equally in all 4 limbs, but could not cooperate for other sensory testing. 

Cerebellar Function:  The patient could not cooperate for cerebellar testing. 

Gait and Stance:  The patient was wheelchair bound due to severe arthritis.

Questions

1.  How would you characterize this patient's language dysfunction?

2.  Damage to what area of the brain gives rise to this type of language dysfunction?  What side of the brain is involved? 

3.  Explain how damage to this area of the brain produces language dysfunction of this type.

4.  In general, what type of pathologic process do you think is involved in this case?

5.  What diagnostic procedure(s) would you undertake at this point?