Case History #58
Date of Consultation: 8-16-1988
HISTORY OF PRESENT ILLNESS:
This 41-year-old right-handed Hispanic male clerk was admitted to the hospital for evaluation of acute onset of vertigo, nausea, and vomiting. Approximately 8 hours prior to admission, the patient was sitting quietly watching TV, when he had the acute onset of a bilateral frontotemporal headache, vertigo consisting of a sensation of his body spinning in space, and nausea and vomiting. He got up to walk to the bathroom because of his nausea and had great difficulty walking with a tendency to veer and fall to the right. He came to the emergency room and was admitted to the hospital. He noted that, if he was very quiet, the vertigo and nausea dampened, but if he moved around at all, they tended to return.
NEUROLOGICAL EXAMINATION:
Mental Status Exam: Intact.
Cranial Nerves: Cranial nerve examination was normal except for a mild degree of horizontal nystagmus in both right and left horizontal gaze.
Motor System: Intact.
Reflexes: Intact and normal.
Sensory System: Intact.
Cerebellar Function: The patient was able to do finger-to-nose, heel-to-shin, rapid alternating movements, and other cerebellar tests of the limbs while in bed without difficulty. When the patient sat up on the edge of the bed, there was difficulty in maintaining the sitting position with a tendency to fall to the right. At times, there was also a tendency to fall forward or backward.
Gait and Stance: Regular gait was performed on a widened base, and the patient tended to stagger from side to side. There was a tendency to veer, fall, or stagger to the right, and the patient noted a feeling that he was falling toward the right. Tandem gait was not attempted. The Romberg test was negative.Questions
1. What is the term for this patient’s findings when he attempted to sit on the side of the bed?
2. Indicate the possible locations of the neurologic lesion and the side of the lesion. Indicate the specific structures involved by the pathologic process.
Signs or Symptoms Site of Lesion Localization
Vertigo
Fall/veer to the right,
with truncal ataxia
3. What type of pathologic process do you think is involved in this case? If vascular, indicate the appropriate vessel.
4. What diagnostic procedure(s) would you undertake at this point?