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Case 30
A 78 year-old right handed woman with hypertension abruptly developed left-sided weakness while
walking her dog in the Sunset with a friend 2 hours ago. She is somnolent, with a blood pressure of
210/100, regular pulse of 70, temperature of 37 C and respirations of 16. Cardiac exam was normal.
She can be aroused only briefly with sternal rub, occasionally following simple commands and speaking
short answers to questions. She has equally reactive pupils, left homonymous hemianopsia, plegia of
the left lower portion face, and her left arm and leg are plegic. Reflexes and tone are decreased on the
left compared with the right. Within 20 minutes of arrival in the ED, her mental status deteriorates further,
necessitating endotracheal intubation.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you treat this patient? How would you
monitor her condition and its treatment? What is the prognosis?
Case 30
A 78 year-old right handed woman with hypertension abruptly developed left-sided weakness while
walking her dog in the Sunset with a friend 2 hours ago. She is somnolent, with a blood pressure of
210/100, regular pulse of 70, temperature of 37 C and respirations of 16. Cardiac exam was normal.
She can be aroused only briefly with sternal rub, occasionally following simple commands and speaking
short answers to questions. She has equally reactive pupils, left homonymous hemianopsia, plegia of
the left lower portion face, and her left arm and leg are plegic. Reflexes and tone are decreased on the
left compared with the right. Within 20 minutes of arrival in the ED, her mental status deteriorates further,
necessitating endotracheal intubation.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you treat this patient? How would you
monitor her condition and its treatment? What is the prognosis?