(Click here for help)
A 65 year-old right handed man with a history of hypertension and smoking comes to the ED with right
face, arm, and leg weakness and slurred speech for eight hours. The symptoms began abruptly during
dinner and have not improved since onset. Examination shows a comfortable, alert man with a blood
pressure of 160/95, regular pulse of 82, temperature of 37 C, and respirations of 16. Cardiac exam was
normal. Mental status was normal and speech was slurred. There was weakness of the right lower face
and paralysis of the right arm and leg. Reflexes were less active in the right arm and leg compared to the
left, and tone was mildly diminished on the right. Plantar responses were flexor bilaterally. Sensory
examination was completely normal.
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, consultations) would you
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? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about his condition and about any proposed
therapy? 65 year-old right handed man with hypertension

Case 20
A 65 year-old right handed man with a history of hypertension and smoking comes to the ED with right
face, arm, and leg weakness and slurred speech for eight hours. The symptoms began abruptly during
dinner and have not improved since onset. Examination shows a comfortable, alert man with a blood
pressure of 160/95, regular pulse of 82, temperature of 37 C, and respirations of 16. Cardiac exam was
normal. Mental status was normal and speech was slurred. There was weakness of the right lower face
and paralysis of the right arm and leg. Reflexes were less active in the right arm and leg compared to the
left, and tone was mildly diminished on the right. Plantar responses were flexor bilaterally. Sensory
examination was completely normal.
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, consultations) would you
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? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about his condition and about any proposed
therapy?|(Click here for help)

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