Case History #184

Date of Admission: 5-9-2010

HISTORY OF PRESENT ILLNESS:

This 75-year-old right-handed African-American male was admitted to the hospital because of speech problems.  He is known to have a past medical history of hypertension, CHF with an ejection fraction of 45 to 50 per cent, and atrial fibrillation.

The patient was well until approximately 10 a.m. on the morning of admission.  At that time, his nephew noted that the patient was unable to speak and his face was twisted.  He was transported to the hospital emergency room where his blood pressure was 199/117.  He was admitted to the hospital and remained stable since that time.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  The patient was awake and alert.  Within the constraints of his language dysfunction, there appeared to be no deficits of memory or orientation.  The patient had no difficulty comprehending spoken language and was able to follow commands without difficulty.  There was no left-right confusion, and the patient was able to demonstrate body parts bilaterally.  Although he could follow commands, he was unable to produce speech at all and therefore was unable to repeat a simple test phrase.

Cranial Nerves:  Sensation of smell and visual acuity were not tested.  Visual fields were full to confrontation, and funduscopic examination was unremarkable.  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.  There was no deviation of his jaw, when opening his mouth widely.  He was able to wrinkle his forehead and elevate his eyebrows symmetrically.  Eyelid closure was also strong bilaterally.  However, when he grimaced or smiled, the right lower facial muscles were not as strong as those on the left.  Hearing was intact bilaterally.  XIth cranial nerve functions were normal.  Tongue and palate appeared normal.

Motor System:  There were no areas of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal (5/5) in all 4 limbs.  There was mild slowing and clumsiness of rapid alternating and rapid repetitive movements in the right hand.

Reflexes:  Intact and symmetric.  Plantar reflexes were flexor bilaterally.  

Sensory System:  Intact.

Cerebellar Function:  Intact.

Gait and Stance:  Not tested.

Questions:

1.  How would you characterize this patient’s language dysfunction?  Damage to what area of the brain typically gives rise to this type of language dysfunction?  Indicate the side of the brain involved. 
   
2.  Considering all of the patient’s signs and symptoms, indicate the area of the brain involved by the pathologic process in this case.  What specific structures are involved by the pathologic process? 
    
3.  In general, what type of pathologic process is involved in this case?
    
4.  What diagnostic procedure(s) would you undertake at this point?