A 59-year-old man with headaches, double vision, dizziness, andataxia
Chief Complaint
A 59-year-old, right-handed male was admitted to the hospitalwith a chief complaint of occipital headaches of 4 daysduration.
History of Chief Complaint
Three days prior to admission, the patient noted a sudden onsetof diplopia on forward gaze and a sensation of dizziness. Thesecomplaints resolved within twenty-four hours. He experiencedseveral episodes of dizziness and diplopia over the next 24 hours.One day prior to admission he noted a relatively sudden onset ofdizziness, diploia and clumsiness in the right hand. Thesecomplaints have persisted since that time.
Medical History
The patient had been under treatment for hypertension for 6years duration with blood pressures in the range of 180/110.
General Physical Examination
The patient was alert, oriented, and cooperative; he was awell-nourished man of medium height who appeared his stated age.Funduscopic examination revealed clear optic disc with sharpborders. The external auditory canal was patent and uninflamed.Pharynx and larynx were non-reddened. A grade II/W bruit waspresent over the right carotid artery. His blood pressure waselevated (192/96). Peripheral pulses were intact at the ankle andwrist. Respirations were normal. His chest was clear toauscultation: skin was warm and of normal texture; abdomen was softwith no tenderness, lumps, or masses. No edema was present in theextremities; no lymphadenopathy was present in the cervical oringuinal areas.
Neurologic Examination
Mental Status. The patient was awake and oriented with respectto person, place, and time. Memory was appropriate for his age.Speech was articulate and meaningful and he could follow three andfour-step commands.
Cranial Nerves. Extraocular movements were full, buttine patient complained of diplopia made worse by lateral gaze tothe left. Nystagmus was present on left lateral gaze. The rightpupil measured 3 mm, the left was 5 mm, but both responded to lightand accommodation. Ptosis of the right eyelid and decreasedsweating on the right side of the face (anhidrosis) were alsopresent. Hearing was diminished in both ears to high frequencies.He admits to a feel of dizziness that he describes as the worldmoving around him. Pain, but not touch sensation, was decreased onthe right side of the face with the exception of some sparingaround the lips and nasal region. The right corneal reflex wasdiminished. Facial expressions were full and symmetric. The uvuladeviated to tile left, and there was deficient elevation of theright side of the palate. There was also a suggestion ofhoarseness.
Motor System. Strength was intact throughout the body;deep tendon reflexes were intact and symmetric. An ataxia wasevident in the right upper extremity on finger-tapping,hand-patting, and finger-to-nose tests. A side-to-side intentiontremor was present. Ataxia was also present in the right lowerextremity, on heel-to-shin and tibia-tapping tests.
Sensory Examination: He had a mild analgesia topinprick on the left side of the body, the left \"'arm, and the leftleg. Position, vibration, and touch modalities were intactthroughout the entire body.
1. Does the patient exhibit a language or memory deficit or analteration in consciousness or cognition? 2. Are signs of cranialnerve dysfunction present? If so, which cranial nerves? 3. Arethere any changes in motor functions, such as reflexes, muscletone, movement, or coordination? 4. Are any changes in sensoryfunctions detectable? 5. Based on the answers to the abovequestions, at what level in the neuraxis is this lesion most likelylocated? 6. Is the pathology focal, multifocal, or diffuse in itsdistribution within the nervous system? 7. What is theclinical-temporal profile of the neurologic pathology in thispatient: acute or chronic; progressive or stable? 8. Based uponyour answers to the above two questions describe the pathologyoccurring in this patient. 9. If you feel this patient’s pathologyis the result of a vascular accident, what vessels are most likelyinvolved?
