Case History #141

Date of Consultation: 2-25-1998

HISTORY OF PRESENT ILLNESS:

This 91-year-old hypertensive white female awoke on 2-24-98 with right-sided weakness and slurred speech.  She came to the emergency room, where her extraocular movements were intact and a mild to moderate right hemiparesis was noted.  She was admitted to the hospital.

The next morning (2-25-98), the patient’s right hemiparesis was more severe, and she noticed horizontal (side-by-side) diplopia with right gaze.  Because of these symptoms neurological consultation was requested. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was normal except for the following.  Visual acuity, visual field, and funduscopic examinations were normal.  External ocular movement testing revealed intact and normal vertical eye movements.  With right gaze, the right eye abducted fully, but the left eye did not move past midline toward the right.  With left horizontal gaze, neither eye moved past the midline toward the left.  Weakness of the right lower facial muscles was present with grimacing.  However, the patient was able to elevate her eyebrows and close her eyes tightly on both sides.  A moderate dysarthria was present.

Motor System:  No evidence of focal muscular atrophy or fasciculations was present.  Muscle tone was normal in all four limbs.  Muscle power was normal on the left side.  On the right side, there was a moderate to marked (2-3/5) weakness of all muscle groups. 

Reflexes:  Deep tendon reflexes were slightly brisker in the right upper and lower limbs than on the left.  Plantar reflexes were flexor on the left and extensor on the right. 

Sensory System:  Intact. 

Cerebellar Function:  Intact.