Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #189

Date of Admission: 8-15-2011


This 52-year-old right-handed Hispanic female Spanish teacher presented to the Emergency Department (ED) with a two week history of intermittent, bilateral frontal and occipital headache associated with photophobia, sonophobia, nausea, and vomiting.  The patient came to the ED one week ago for knee pain after a fall, and she was given Norco for the pain.  The medication exacerbated her nausea and vomiting; so she returned to the ED a few days later.  A G-I evaluation was negative, and her pain medication was changed to extra strength Tylenol.  However, her headache, nausea, and vomiting continued, and she once again returned to the ED.  This time a CT scan was obtained, and she was admitted to the hospital for further evaluation.

Her neurological review of systems was entirely unremarkable, except that the patient thought the vision in her right eye was somewhat diminished.  She denied any cognitive problems, numbness, weakness, clumsiness, vertigo, diplopia, or any other neurological symptoms.  Likewise, her past medical history was unremarkable and did not include hypertension, diabetes, hyperlipidemia, tobacco use, or illicit drug use. 


Mental Status Exam:  Intact.

Cranial Nerves:  Sensation of smell was not tested.  Visual acuity and funduscopic examination were normal.  Visual field testing revealed difficulty seeing objects in the right half of the visual field of each eye.  Extraocular movements were full without nystagmus or diplopia.  Pupils were equal, round, and reactive to light.  Ptosis was not present in either eye.  Sensory and motor functions of the trigeminal nerves were normal bilaterally.  No facial weakness was present.  Hearing was intact bilaterally.  Tongue and palate were normal and midline.  No weakness of XIth cranial nerve muscles was present.

Motor System:  There was no evidence of focal muscular atrophy or fasciculations.  Muscle tone and power were normal in all four limbs.  No involuntary movements were present. 

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

Sensory System:  Sensory examination was normal in all four limbs.

Cerebellar Function:  All cerebellar tests were performed normally, including finger-to-nose and heel-to-shin tests. No evidence of intention tremor, dysmetria, or dyssynergia was present. 

Gait and Stance:  Regular and tandem gait were performed normally, and the Romberg test was negative.  The patient walked on her heels and toes without difficulty.


1.  How would you describe this patient’s visual findings?

2.  Concerning her visual symptoms, indicate the specific structures involved in producing these signs and symptoms.  Is there only one anatomical location that can produce these visual signs and symptoms?  If so, what is that location?  If not, what are the possible locations of such a lesion?

3.  Considering her entire history and examination, what type of pathologic process do you think is involved in this case?

4.  What is the most likely pathologic diagnosis?

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


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