Case History #51
Date of Admission: 2-4-1988
HISTORY OF PRESENT ILLNESS:
This 90-year-old white right-handed female was admitted to the hospital for a possible episode of loss of consciousness. Approximately 2 hours prior to admission, the patient noted the abrupt onset of wooziness, lightheadedness, and then true vertigo. These symptoms resolved after several minutes. She was not entirely certain that she lost consciousness but indicated that there was a period of time that she cannot account for.
NEUROLOGICAL EXAMINATION:
Mental Status Exam: Intact.
Cranial Nerves: Cranial nerve examination was normal except for the following. There was an asymmetry of the face with flattening of the left nasolabial fold. When asked to elevate the eyebrows, the left forehead muscles did not contract as strongly as those on the right. The patient was unable to completely close the left eye, whereas that movement was complete on the right side. When asked to smile or grimace, the left side of the mouth moved much more weakly than the right side.
Motor System: There were no areas of focal muscular atrophy. There were no fasciculations. Muscle tone was normal in all 4 limbs. Muscle power was normal (5/5) on the left side. On the right side, there was a mild weakness (4/5) in both the upper and lower limbs with the upper limb being more involved than the lower.
Reflexes: Deep tendon reflexes were normal (2/4) on the left side and increased (3/4) on the right side. Plantar reflexes were flexor on the left and extensor on the right.
Sensory System: Intact.
Cerebellar Function: Intact.
Gait and Stance: Regular gait was performed slowly and cautiously but on a fairly narrow base and without evidence of ataxia or spasticity. The Romberg test was negative. Tandem gait was not attempted.
Questions:
1. Do the findings on the right side of the body indicate an upper motor neuron or lower motor neuron lesion?
2. Do the findings involving the left side of the face indicate an upper motor neuron or lower motor neuron lesion?
3. Considering the entire clinical picture, what specific structure(s) is (are) involved to produce the patient’s left facial weakness?
4. Considering the entire clinical picture, what specific structure(s) is (are) involved to produce the patient’s mild right hemiparesis, hyperreflexia, and extensor plantar reflex?
5. Where is this patient’s neurological lesion located?
6. In general, what type of pathologic process was involved in this case?
7. What diagnostic procedure(s) would you undertake at this point?