Chapter 6 Case Studies
Case #1 Sudden Onset of Right Hand Weakness
A 64 year old man developed right hand weakness following a cardiac arrest
The patient had a history of hypertension and cigarette use but was otherwise healthy until the
day of admission, when he suddenly collapsed in church.
Family members at the scene
administered immediate CPR, and when the ambulance arrived, the patient received electrical
defibrillation and promptly regained normal cardiac rhythm.
He was admitted to the cardiac
intensive care unit and was found to have episodes of rapid atrial fibrillation.
Several days after
admission he was noted to have
weakness and spasticity of the right hand,
and a neurologic
consult was requested.
Vital signs: Temperature = 98º, Pulse = 100, BP = 130/60, Respiration = 18
Neck: supple with no bruits
Heart: Irregular rhythm, with a soft systolic murmur
Abdomen: normal bowel sounds, soft, nontender
: alert and oriented x3.
Language fluent, with intact naming, repetition,
Able to recall 3/3 objects after 5 minutes.
normal, including no facial weakness
: muscle strength 5/5 throughout, except right hand and wrist.
flexion, extension, and hand grip 3/5.
Right finger extension, abduction,
adduction, and thumb opposition 0/5.
: all grade 2 with normal plantar reflex
Coordination and gait
: not tested
: intact light touch, pinprick, joint position, and vibration sense.
on double simultaneous stimulation.
Localization and differential diagnosis
On the basis of the symptoms and signs shown in bold above, where is the lesion?
Given the relatively acute onset of the deficits, and the presence of atrial fibrillation, what
is the most likely diagnosis?
Case #2 Sudden Onset of Left Foot Weakness
An 81 year old woman presented to the emergency room with left foot weakness.
The patient was previously healthy except for a history of hypertension and diabetes.
morning of admission, as she got out of bed she noticed difficulty when she first put her foot on
As she tried to walk she felt that she was
dragging her left foot.
continued her usual morning activities, using a chair for support.
Later that morning, when the
gait difficulty persisted, she called her children, who brought her to the emergency room.
had no other complaints except for a mild
right frontal headache.