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Thread: A 77-year-old man, was well except for mild hypertension controlled by medication.

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    Question A 77-year-old man, was well except for mild hypertension controlled by medication.

    Fred's Flaccid Face

    Fred, a 77-year-old man, was well except for mild hypertension controlled by medication. On the day of admission, he became nauseated and vomited twice. He then noted right-sided numbness and drooping of the left side of his face.


    Examination:


    Examination an hour later revealed a blood pressure of 200/100. He was alert with normal speech. His pupils were equal and reactive. He was unable to gaze to the left with either eye; and when he tried to look tot he right, his right eye abducted, but the left did not move. His left facial muscles were weak, including the corrugator. The remainder of his muscle strength was normal, and reflex changes were present. Pain, light touch, joint position, and vibratory sense were impaired on the right.
    How To Solve This Case

    Your goal in solving this case is to:

    1. Determine the location of the lesion in the central nervous system
    2. Determine the most likely type of lesion, such as tumor, vascular occlusion, toxin, disease, etc.
    To do this, you first must summarize the case, noting the types of sensory, motor, and general deficits and the "sidedness" of those deficits - whether all of the the deficits on the same side, both sides, or alternating. Once you have done this, you are ready to determine the location of the lesion...


    Questions To Be Asked To Determine the Lesion Location

    These are some questions to ask yourself in determining the location of the lesion:

    • Is there higher level dysfunction, such as memory loss, agnosia, or apraxia, for example?
      --If so, consider cortical lesions.
    • Is there both upper and lower motoneuron paralysis/weakness, without cranial nerve deficits?
      --If so, consider lesions of the spinal cord.
    • Are there alternating cranial nerve and sensory/motor deficits?
      --If so, consider lesions of the brainstem.
    • Are there unilateral lower motoneuron and sensory deficits?
      --If so, consider peripheral nerve lesions.
      --Are there meaningless, unexpected, unintentional movements, without paralysis or significant weakness?
    • If so, consider lesions of the basal ganglia.
    • Are there awkward though intentional movements, such as tremor, without paralysis or significant weakness?
      --If so, consider lesions of the cerebellum.
    • Is internuclear opthalmoplegia the only sign/symptom?
      --If so, consider lesions of the brainstem.


    .
    Last edited by trimurtulu; 12-19-2008 at 11:15 AM.

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