Case History #19

Date of Consultation: 2-23-1987

HISTORY OF PRESENT ILLNESS:

This 67-year-old right-handed white male carpenter was admitted to the hospital for an episode of syncope.  Two days prior to admission, the patient noted the acute onset of lightheadedness, and when he attempted to walk to the bathroom,  he had a tendency to veer to the right and was unsteady on his feet.  After returning to the bedroom, the patient had a syncopal episode.  When he awakened from this loss of consciousness, he noted that his voice was extremely hoarse, and he could speak only in a whisper.  Soon thereafter he noted hiccups and dysphagia.  He was admitted to the hospital for further observation and evaluation.  He remained stable after admission, although he continued to have difficulty with swallowing and tended to choke on both liquids and solid food.

PAST MEDICAL HISTORY:

This patient's past medical history was significant for hypertension, hypercholesterolemia, probable diabetes, cardiac arrhythmia consisting of both sick sinus syndrome and atrial fibrillation, and he was status post left hemisphere stroke in 1976 with an essentially complete recovery. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact except for speech which was extremely hoarse and dysphonic. There was no aphasia present, and the words were not slurred but merely extremely hoarse and quiet. 

Cranial Nerves:  Cranial nerve examination was normal except for the following.  The right pupil was 2 mm in diameter, and the left pupil was 4 mm.  Both reacted normally to light.  There was a 1 mm ptosis of the right eyelid.  External ocular movements appeared intact, although there was nystagmus in right gaze and downgaze.  The nystagmus was usually right beating although at times it had a rotary component to it.  Sensory testing of the face revealed a decreased appreciation of pinprick on the right side of the face, and the right corneal reflex was diminished.  The uvula and palate deviated to the left. 

Motor System:  Intact.

Reflexes:  Intact, symmetric, and the plantar reflexes were flexor bilaterally.

Sensory System:  Sensory examination revealed a decreased appreciation of pinprick on the entire left side of the body.  Joint position sense, vibration, and touch were intact on the left.  All modalities of sensation were normal on the right. 

Cerebellar Function:  The patient performed all cerebellar tests normally on the left.  On the right side, the patient exhibited a mild to moderate degree of dysmetria and dyssynergia.  There was an intention tremor present in the right upper and lower limbs. 

Gait and Stance:  Regular gait was performed on a wide base with some degree of instability. There was a tendency to fall to the right.  Tandem gait was extremely difficult, again with a tendency to fall to the right.  The Romberg test was negative. 

Questions

1.  Indicate the structures involved by the pathologic process to produce each of the signs and symptoms in this patient.

Signs or Symptoms                  Site of Lesion                              

Syncope                                  
                                                                                                           
Ataxia, veer to R                      

Dysphonia, palate to L,           
dysphagia                                

R  miosis, ptosis                       
                                               

Dec. pain, R  face                    

Dec. pain, L  body                   

R  cerebellar signs                 

2.  The findings in this case constitute a classic neurologic syndrome.  Indicate the location of the neurologic lesion and the name of the syndrome.

3.  In general, 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?