A 65-Year-Old Man Comes to the Emergency Department Due to Acute

question 109

Multiple Choice

A 65-year-old man comes to the emergency department due to acute onset of headache, double vision, slurred speech, and left-sided weakness.  The patient describes his headache as a throbbing pain at the back of the head.  He has had no nausea, vomiting, hiccups, numbness, or difficulty swallowing.  The patient has a history of hypertension and hyperlipidemia.  Medications include aspirin, lisinopril, and atorvastatin.  He is a retired truck driver and smokes a pack of cigarettes a day.
Blood pressure is 170/90 mm Hg and pulse is 90/min with regular rhythm.  Funduscopic examination is normal with no papilledema.  There is no nystagmus; however, there is complete ptosis of the right eye that is depressed and deviated to the right.  The right pupil is dilated and nonreactive to light.  Confrontational visual fields are normal.  There is left lower facial droop.  The cough and gag reflexes are intact.  The tongue is midline with no fasciculations.  There is left-sided hemiplegia with an extensor plantar response.  There is also increased cogwheel rigidity in the left upper extremity.
A non contrast CT scan of the head is negative for acute hemorrhage.
A lesion in which of the following areas is most likely responsible for this patient's symptoms?

• A)Brainstem at the level of the medulla oblongata
• B)Brainstem at the level of the midbrain
• C)Cerebellar hemisphere
• D)Cerebral cortex in the distribution of the middle cerebral artery
• E)Posterior limb of the internal capsule

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