CASE1

Mrs Doe is a 66-year-old woman who presents to the emergency department at 10.10 am having
been brought to hospital by ambulance. She seems to be having some difficulty in making herself
understood, and is unable to give a clear account of what has happened. Unfortunately the
ambulance crew have left the hospital on another call, and there is no information available on
how she got to hospital.

She is breathing without difficulty or respiratory distress, has a pulse of 103 beats/min, which is
irregularly irregular in time, force and volume, and has a blood pressure of 176/97mmHg. She is
apyrexial, with a capillary blood glucose of 6.4mmol/L.

Just then her daughter telephones the emergency department from another city some miles away,
to enquire after her mother. You manage to speak to her on the phone, and she is clearly in some
distress. She tells you her mother has previously enjoyed good health without hypertension or
diabetes, and as far as she knows has never been on a tablet to thin her blood. Her mother
worked as a shop assistant until her retirement 6 years ago, walks the dogs for half a mile each
day and swims once a week. She last spoke to her mother 5 days ago, at which time she was well
and had no complaints. She knows her mother is in hospital because a neighbor saw an
ambulance outside the local newsagent and was shocked to discover who they had come for.
Apparently her mother had come over ‘all queer’ while buying a pint of milk.

On telephoning the newsagent you learn that your patient was completely normal when she went
in to the shop. Suddenly, at about 09.20 am, she appeared to be unsteady on her feet, she dropped
her purse from her right hand, turned to speak to the shopkeeper but was able to say only ‘dog ...
speak ... help’. It is now 10.40 am.

Initial neurological examination shows her to be alert but to have communication difficulties; she
is able to obey one stage (stick out your tongue) but not three stage (point to the ceiling after
pointing to the door) commands. The right side of her face is drooping, her right arm and leg lie
flaccid at her side with no spontaneous movements, and she is able to move the left arm and leg
briskly to command. She appears to have a right homonymous hemianopia.

Questions

1. Enumerate the clinical manifestation of the patient

2. Localize the patients manifestation
3. What is the possible etiology
CASE 2

A 55-year-old right-handed woman is brought to the emergency department by the police

because of unusual behavior. When she was at the grocery store, she started talking unintelli-
gibly. She asked for the “luoi” (presumably refer- ring to “oil”) and the “froogles”(presumably
“noodles”) and became very irritated when the grocery assistant did not understand her. On
neurologic examination, she was alert and her speech was fluent and nondysarthric. However,
she could not follow spoken commands, but she could imitate gestures. She was unable to
repeat words, read, or write. The rest of the neurologic examination was normal.

Questions:
1. What does this disorder represent?
2. What is the most likely location of the lesion?
3. What is the arterial supply of this area?

CASE 3
A 65-year-old right-handed lawyer suddenly became mute and agitated. On neurologic exam-
ination, he was alert, producing rare guttural sounds but not recognizable words. He could
follow occasional simple commands but could not repeat a three-word sentence. He appeared
frustrated by his inability to do so. He had mild weakness of the right lower face, weakness of
the right upper extremity, and decreased rate of alternate motion in the fingers of the right
hand.

Questions:
1. What does this problem represent?
2. What is the most likely location of the lesion?
3. What artery supplies the affected region?

Three months later, his speech was still nonflu- ent and poorly articulated. He was unable to
control movement of the lips, tongue, and lower jaw for producing words such as
“catastrophe.”

4. What is the term used to describe the inability to perform articulatory movements to
produce speech sounds?