Question

A 76-year-old woman was brought to the emergency room by ambulance after being found at home confused and incoherent. The patient has a history of diabetes, coronary disease, and congestive heart failure. At baseline, she was living independently in her own apartment. A friend had been unable to reach the patient for one week, so she went to check on the patient on the day of admission. She found the patient incoherent, disheveled, and with her house in disarray. An ambulance was called, and the EMTs were reportedly barely able to walk in the house due to clutter all over the floor. On arrival at the emergency room, the patient was unable to provide further details of what happened. She was suspicious and belligerent initially, kicking the emergency room staff. PHYSICAL EXAMINATION Unkempt woman in restraints. Vital signs: T = 98.7°F, P = 75, BP = 126/73, R = 12 Neck: Supple. Lungs: Clear. Heart: Regular rate with soft systolic ejection murmur. Abdomen: Normal. Extremities: No edema. Neurologic exam: Mental status: Alert, speaking with spontaneous fluent speech that made no sense. Responded to most questions by saying "sample, ok" or "yeah." She had calmed down at the time of the exam and had a pleasant affect and appeared sociable. Had frequent paraphasias and neologisms. Followed almost no commands, for example, would not raise arms on command, touch her nose, or squeeze and release hands, but did close and open eyes on command. Did imitate simple non-verbal gestures, for example, to raise her arms. Could not name any objects. Could not repeat even single words. Was unable to read or follow written commands. CRANIAL NERVES: PERRL, EOMI, no nystagmus. Visual fields: Decreased blink to threat on the right side. Face symmetric. Palate and tongue: Midline. Sternomastoid strength normal on limited exam. Motor: Normal muscle bulk and tone. 5/5 strength throughout. Reflexes: COORDINATION: Reached for objects without ataxia. GAIT: Normal. Sensory: Withdrew normally to gentle pinch in all extremities. 5. Where can a single lesion cause all of the deficits seen in our patient? 6. What factors in the patient's history make one particular diagnosis most likely, and what is this diagnosis? What are some other possibilities? 7. Which cerebral blood vessel, and what division of that vessel supplies the involved region of the brain? 8. What is the most likely localization and diagnosis? 9. What is your final diagnosis?

A 76-year-old woman was brought to the emergency room by ambulance after being found at home confused and incoherent. The patient has a history of diabetes, coronary disease, and congestive heart failure. At baseline, she was living independently in her own apartment. A friend had been unable to reach the patient for one week, so she went to check on the patient on the day of admission. She found the patient incoherent, disheveled, and with her house in disarray. An ambulance was called, and the EMTs were reportedly barely able to walk in the house due to clutter all over the floor. On arrival at the emergency room, the patient was unable to provide further details of what happened. She was suspicious and belligerent initially, kicking the emergency room staff.

PHYSICAL EXAMINATION
Unkempt woman in restraints.
Vital signs: T = 98.7°F, P = 75, BP = 126/73, R = 12
Neck: Supple.
Lungs: Clear.
Heart: Regular rate with soft systolic ejection murmur.
Abdomen: Normal.
Extremities: No edema.
Neurologic exam:
Mental status: Alert, speaking with spontaneous fluent speech that made no sense. Responded to most questions by saying "sample, ok" or "yeah." She had calmed down at the time of the exam and had a pleasant affect and appeared sociable. Had frequent paraphasias and neologisms. Followed almost no commands, for example, would not raise arms on command, touch her nose, or squeeze and release hands, but did close and open eyes on command. Did imitate simple non-verbal gestures, for example, to raise her arms.
Could not name any objects. Could not repeat even single words. Was unable to read or follow written commands.
CRANIAL NERVES: PERRL, EOMI, no nystagmus.
Visual fields: Decreased blink to threat on the right side.
Face symmetric.
Palate and tongue: Midline. Sternomastoid strength normal on limited exam.
Motor: Normal muscle bulk and tone. 5/5 strength throughout.
Reflexes:
COORDINATION: Reached for objects without ataxia.
GAIT: Normal.
Sensory: Withdrew normally to gentle pinch in all extremities.

5. Where can a single lesion cause all of the deficits seen in our patient?
6. What factors in the patient's history make one particular diagnosis most likely, and what is this diagnosis? What are some other possibilities?
7. Which cerebral blood vessel, and what division of that vessel supplies the involved region of the brain?
8. What is the most likely localization and diagnosis?
9. What is your final diagnosis?

Added by Dwayne O.

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