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Markings on a paper by elderly man

Markings on a paper by elderly man

This article was originally presented as an independent educational activity under the direction of CME LLC. The ability to receive CME credits has expired. The article is now presented here for your reference. CME LLC is no longer responsible for the presentation of the article.

The Case
A left-handed 84-year-old retired attorney is seen for a routine scheduled visit 5 months after a stroke. The nondominant hemisphere was affected by an embolism that arose in the newly fibrillating left atrium. Dense right hemiparesis has since eased considerably, largely because of much rehabilitation therapy. Documented right homonymous hemianopsia has been accompanied by hemineglect and extinction on bilateral simultaneous sensory stimulation. Primary sensory function is intact.

Voices no complaints. His wife says he is "holding his own."

Heart rate, 72 beats/min and regular. Participates well in conversation and interacts with both the physician and his caregiver spouse. Right-sided weakness has eased but is still detectable. When asked to cross out all the lines on a preprinted form, he completes the test as shown.

More History/Physical
Has organic heart disease with atrial fibrillation that was first noted at time of stroke. Intellectually has been one step slower than before the stroke, but still reads avidly.

Hard of hearing, impairment in this domain evident. Interested and sensible in conversation; range of topics discussed diminished from when it was pre-stroke. Lungs clear to auscultation. Heart reveals no S3. Bilateral simultaneous stimulation not retested. Tends to attend better when approached from the right than from the left; seems to move his head to keep speaker in view. Gait is limited and required assist device and help of one person.

Laboratory Findings
Creatinine 1.5 mg/dl. Hct 38%. B12, TSH and VDRL not retested: were normal during acute phase of stroke.

What's Your Diagnosis?

Compensatory action
Organic psychosis

(Answer on next page.)


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