Case History #163

Date of Admission: 12-28-2009

HISTORY OF PRESENT ILLNESS:

This 73-year-old right-handed African-American female retired nurse was admitted to the hospital because of left-sided weakness.  When the patient woke up on the morning of admission, she felt that her left side was a little weak but did not think much about it.  About 10:00 a.m., her cousin came by and noticed that the left side of her face was “twisted”.  Because of these symptoms, she came to the emergency room and was admitted to the neurology service. 

The patient had no other neurologic or systemic signs or symptoms and had never had an event similar to this in the past. 

The patient denied a past history of hypertension, diabetes, tobacco use, or hyperlipidemia.  She was taking no prescription medications. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  No deficits of orientation, speech, or memory were present.  The patient’s mood was judged to be normal. 

Cranial Nerves:  Sensation of smell was not tested.  Visual field, visual acuity, and funduscopic examinations were normal.  External ocular movements were full without nystagmus or diplopia.  Pupils were equal, round, and reactive to light.  Sensory and motor functions of the Vth cranial nerve were normal.  Weakness of the lower facial muscles on the left was appreciated.  However, the patient was able to wrinkle her forehead, elevate her eyebrows, and close her eyes tightly.  Hearing was intact bilaterally.  XIth cranial nerve functions were normal.  Tongue and palate appeared normal.

Motor System:  There were no areas of focal muscular atrophy.  There were no fasciculations.  Muscle tone was normal bilaterally.  Muscle power was normal on the right.  There was a diffuse, but mild weakness (4+/5) in the left upper and lower limbs.

Reflexes:  Deep tendon reflexes were equal and symmetric.  Plantar reflexes were flexor on the right and extensor on the left. 

Sensory System:  The patient perceived all modalities of sensation, including cortical sensations, normally bilaterally.

Cerebellar Function:  Intact.

Gait and Stance:  Regular gait was performed with a mild degree of circumduction of the left lower limb.  Tandem gait was performed adequately.  The Romberg test was negative.

Questions:

1.  Considering this patient’s history and physical examination, how precisely can the neurologic lesion be localized in this case?

2.  Indicate the level of the neurologic lesion in this case as precisely as possible and the structures involved by the pathologic process.  If precise localization is not possible, list as many levels and/or structures as you can that might produce the same clinical picture, if involved by the pathologic process.

3.  The findings in this case represent a classic neurologic syndrome.  What is the name of that syndrome, and what is its usual cause?

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?