Sam, a 72-year-old right-handed man with a previous history of hypertension, awoke one morning with the sensation that the room was spinning. He was nauseated and vomiting; he also noted hoarseness, inability to swallow, and numbness of the right side of his face and the left side of his body.
On examination, he was awake and alert, with normal mentation. His speech was hoarse but not dysphasic. The right pupil was 2mm, the left was 5 mm, and both reacted to light. The right eyelid drooped, and the right corneal reflex was depressed. Nystagmus was present and was maximum on gaze to the right. The ability to sense pin prick and hot and cold was diminished over the right face and left body. The soft palate elevated to the left on phonation, the gag reflex was absent on the right, and, on indirect laryngoscopy, the right vocal cord was observed to be immobile. Muscle strength was normal, but tone was diminished in the right arm and leg, and there was incoordination on the right (arm more than leg). The tendon reflexes were slightly diminished on the right. The plantar reflexes were flexor.
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