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62 year-old man Unable to Speak
A 62 year-old man was brought to the emergency department 45 minutes after the sudden onset of
inability to speak and right-sided weakness that began while eating breakfast with his wife. On
examination, the temperature is 37 C, blood pressure is 160/80, pulse is regular at 80, and respirations
are 18. General physical examination, including detailed cardiac examination, is normal. On neurologic
exam, the patient is alert and can follow simple commands, but only utters occasional unintelligible
sounds. He has equally reactive pupils, a left forced gaze deviation, right homonymous hemianopia,
moderate weakness of the right lower face, right pronator drift, and moderate pyramidal weakness of the right arm. The right leg appeared to have full power. Tone and reflexes were diminished in the right arm. click here
Sensory exam revealed decreased light touch and pin prick sensation in the right arm and face.
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 manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?
A 62 year-old man was brought to the emergency department 45 minutes after the sudden onset of
inability to speak and right-sided weakness that began while eating breakfast with his wife. On
examination, the temperature is 37 C, blood pressure is 160/80, pulse is regular at 80, and respirations
are 18. General physical examination, including detailed cardiac examination, is normal. On neurologic
exam, the patient is alert and can follow simple commands, but only utters occasional unintelligible
sounds. He has equally reactive pupils, a left forced gaze deviation, right homonymous hemianopia,
moderate weakness of the right lower face, right pronator drift, and moderate pyramidal weakness of the
right arm. The right leg appeared to have full power. Tone and reflexes were diminished in the right arm.
Sensory exam revealed decreased light touch and pin prick sensation in the right arm and face.
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 manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?