Case History #38

Date of Consultation: 11-29-1987

This 77-year-old right-handed white female housewife was admitted to the hospital on 11-10-87 for a colon obstruction.  A colostomy was performed on 11-11-87, and the patient was recovering quite well postoperatively until 11-29-87, when she had the acute onset of neurologic symptoms. 

At 6:30 a.m. on 11-29-87, the patient experienced the acute onset of lethargy, disorientation, weakness of the right lower face, and right-sided weakness.  She improved somewhat from that state, became more alert, but continued to have a right hemiparesis and difficulty with language function.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  The patient was alert and awake, but testing of higher intellectual functions was severely limited due to her language dysfunction.  She produced fluent speech, but there was a tendency to repeat the same phrases over and over again (perseveration).  She appeared to comprehend spoken language and followed most commands appropriately.  However, when asked to repeat a test phrase such as "no ifs, ands, or buts" or "Tom and Bill went fishing," she was unable to do so.  Her reading and writing abilities could not be adequately tested because of her weakness and difficulty with sustained language production. 

Cranial Nerves:  Cranial nerve examination was normal, except for a mild weakness of the lower facial muscles on the right. 

Motor System:  There were no areas of focal muscular atrophy.  There were no fasciculations.  Muscle tone was normal on the left and flaccid on the right.  Muscle power was normal on the left and moderately weak in the right upper limb, being rated at 2 to 3/5.  The right lower limb was essentially plegic (0-1/5).

Reflexes:  Deep tendon reflexes were symmetric in the upper limbs.  In the lower limbs, reflexes were diminished in the right lower limb when compared to the left.  The left plantar reflex was flexor, and the right plantar reflex was extensor. 

Sensory System:  Reliable sensory testing could not be performed due to her language dysfunction.  She did appear to perceive pain in all four limbs. 

Cerebellar Function:  Not tested.

Gait and Stance:  Not tested.

Questions:

1.  How would you characterize this patient's language dysfunction?  

2.  What specific structures are involved to produce the patient’s aphasia?

3.  Is the right facial weakness of the upper motor neuron or lower motor neuron type?

4.  What specific structures are involved to produce the right UMN facial weakness?

5.  What specific structures are involved to produce the right-sided weakness?

6.  What is the location of the neurologic lesion, and which side of the nervous system is involved? 

7.  In general, what type of pathologic process is involved in this case?

8.  What diagnostic procedure would you undertake at this point?