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Application Exercise Handout

Application Exercise Handout
Case 1
Unconsciousness, left sided weakness and dysconjugate gaze.
A 75 year old man with a history of hypertension was found unconscious on the floor.
At the emergency room his vital signs were normal and he was lying with his eyes closed. He
occasionally moved his right extremities. His left leg was externally rotated at the hip. With expiration,
his right cheek appeared to puff out more than his left, and his right forehead appeared less furrowed. He
did not respond to his name being called or to being shaken. When pricked with a pin on either side of his
body he grimaced and tried to brush off the stimulus with his right arm. In grimacing, only the left corner
of his mouth lifted.
When his eyelids were held open, his right eye deviated to the left while his left eye stared straight
ahead (see a - below). When his head was rapidly turned to the left his right eye moved to the middle and
stopped while his left eye moved fully to the right (see b - below). When his head was quickly turned to
the right, both eyes moved conjugately to the left (see c - below). When his head was rotated up and
down, both eyes moved appropriately (in the opposite direction to the movement). There was eyelid
closure on the left but not on the right when either the right or left cornea was touched. The gag reflex was
present on both sides. Tone was increased on the patient's left side, tendon reflexes were brisk, and
Babinski's sign was present.
right left

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Questions for Case 1:

1. The lack of eye-lid closure on the right is due to involvement of the
A. facial motor nerve (nerve root or nucleus) on the right.
B. corticobulbar fibers on the left.
C. trigeminal nerve on the right.
D. oculomotor nerve on the right.
2. His eye movement problem is due to a lesion of the
A. right oculomotor nerve.
B. right paramedian pontine reticular formation (PPRF).
C. left paramedian pontine reticular formation (PPRF).
D. right abducens nerve.
E. right abducens nucleus.
3. The history and examination suggest the most likely explanation for this man's problem is
A. a tumor beginning in the IV ventricle and pushing downward onto the pontine tegmentum involving
the abducens nucleus, facial motor nucleus, reticular formation and finally the corticospinal tract on
the right.
B. a lacunar infarct of a penetrating circumferential branch of the basilar artery involving the motor
nucleus of CN VII, corticospinal tract, reticular formation and the abducens nerve root on the right.
C. an infarct of a paramedian branch of the basilar artery involving the abducens nucleus, internal genu
of the facial nerve, medial longitudinal fasciculus and reticular formation, but sparing the
anterolateral system in the lateral pontine tegmentum.
D. a degenerative bulbar palsy affecting the motor nuclei of CN VI and VII, bilaterally.
Application Exercise Handout
Case 2
Double vision and weakness of both lower extremities.
A 56-year-old IV drug user with 3 weeks of frontal head pain and drooping of the left eyelid
(ptosis) and progressive difficulty with gait. When he held the left eyelid open, he noticed double vision
when looking in any direction except straight ahead. Several days later he noted numbness of his left
forehead when combing his hair. The symptoms worsened progressively. He also complained that his
legs were weak and he was staggering, especially when it was dark. Sometimes his legs would buckle
and he would fall. He also began to have urgency of micturation and at times he would become
incontinent. He complained of a tightness of the chest “like he had on a tight girdle”. He was a severe
diabetic and smoked 1 pack of cigarettes daily.
He was alert and oriented, with fluent and well-articulated speech. Visual fields were intact. The
right pupil was 3 mm in diameter and normally reactive to light. The left pupil was 5 mm in diameter and
unresponsive to light. The patient could not move his left eye from the straight-ahead position.
Movements of the right eye were normal. There was decreased sensation to pinprick in areas innervated
by the left trigeminal nerve (ophthalmic and maxillary divisions).
Motor system examination showed grade 3-4/5 weakness in the lower extremities, grade 5/5 in all
muscle groups in the upper extremities. There was no atrophy or fasciculation. Tone was increased in the
Sensory examination showed impaired position and vibration sensation in his legs. Romberg’s
sign was positive. Reflex examination showed that the biceps, triceps and brachioradial reflexes were
normal. Knee and ankle reflexes were hyperactive. Sustained clonus and Babinski signs were seen

Questions for Case 2:

4. The positive Romberg sign in this case is due to
A. weakness.
B. loss of pain and temperature.
C. loss of position sensation.
D. hyperreflexia.
E. cerebellar ataxia.
5. Which set of these symptom combinations is the best indicator of an upper motor neuron lesion?
A. weakness, hyperreflexia, Romberg sign, increased tone
B. weakness, hyporeflexia, atrophy, Babinski sign
C. weakness, increased tone, Babinski sign, fasciculations
D. hyperreflexia, increased tone, Babinski sign, clonus
6. The arms have normal strength and reflexes, but the legs show weakness, hyperreflexia, clonus and
Babinski signs, bilaterally. This indicates a lesion located
A. is probably a peripheral polyneuropathy due to a combination of the patient's diabetes and
excessive smoking.
B. has completely destroyed the lumbar and sacral regions of the spinal cord, bilaterally.
C. must be located in the brainstem above the level of the pyramidal decussation and on the right
D. was probably caused by bilateral infarcts of the middle cerebral arteries destroying the lateral parts
of both precentral gyri.
E. is located somewhere in the thoracic spinal cord region, below the cervical enlargement but above
the lumbosacral enlargement.

Application Exercise Handout

7. The best localization of the lesion in this patient is

Write your localization on the Post-it paper (15 words or less), along with your Team number, and
tape it to the white board down front. We will coalesce the 18 Team localizations into 5 choices,
allow you time to discuss each of the 5 choices within your Team, THEN vote.