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Case 39
A 34 year-old woman was evaluated 6 hours after the sudden onset of dysphagia, vertigo, nausea,
vomiting, and ataxia. On examination, her mental status is normal. On cranial nerve examination, the
left pupil is smaller than the right but reactive, with ptosis on the left. Eye movements are full with rightbeating nystagmus. There is decreased sensation to temperature and pain in the left face. The left
palate does not elevate. Motor and reflex examinations are normal. There is decreased pinprick and
temperature in the right arm and leg although vibratory testing is normal. The left arm and leg are
clumsy.
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 39
A 34 year-old woman was evaluated 6 hours after the sudden onset of dysphagia, vertigo, nausea,
vomiting, and ataxia. On examination, her mental status is normal. On cranial nerve examination, the
left pupil is smaller than the right but reactive, with ptosis on the left. Eye movements are full with rightbeating nystagmus. There is decreased sensation to temperature and pain in the left face. The left
palate does not elevate. Motor and reflex examinations are normal. There is decreased pinprick and
temperature in the right arm and leg although vibratory testing is normal. The left arm and leg are
clumsy.
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?