CLINICAL CASE ANALYSES: CEREBRUM AND HIGHER CORTICAL FUNCTION

Instructions:

All sections will answer all questions. In the Oral Reporting, Sections 1 and 2 will report the cases highlighted in yellow, whereas,
Sections 3 and 4 will report the cases highlighted in pink.

Type in your answers here and change the font color to blue. Indicate references in APA format, and submit back in pdf format.
References to be accepted are from books, journals, scholarly articles and websites.

CLINICAL QUESTION 1: Cerebrovascular Accident (Stroke) Section 1 and 2; Sections 3 and 4

1) Define CVA (short definition and discussion only)
CVA is short for cerebrovascular accident, also known as stroke.
2) What are the most common clinical signs/symptoms of patients with CVA of the cerebrum? You may base you
answers on your knowledge on cerebrum, or may research on this from your books. Fill the table below with 10
common clinical s/sx with a corresponding localization of lesion.

Clinical Sign/Symptom Possible Area of Lesion in the Nervous System/Brain

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

CLINICAL CASE 1: A man who talks non-sense Sections 1 and 2

You are a physical therapist working in a neurorehabilitation facility. Your first patient today is a new referral from the
physiatrist in charge of your clinic. You met your patient and saw that he is clearly agitated and talks gibberish. You started
asking questions to know his clinical history, but he says very little, but when he does speak, it is non-sensical. He cannot repeat
words nor understand, and obey your instructions, which frustrate you because you cannot complete your PT examination. Being
a good physical therapist that you are, you still tried your best to examine your patient, which revealed the following findings: he
appears to have lost his right visual field in both eyes, his eyes are driven to the left, and cannot look towards the right. She has
a right-sided facial droop, but the tongue, uvula and palate are in midline (normal). Motor examination reveals: increase in
muscle tone of the right upper and lower extremities, increased reflexes on the right side (hyperreflexia, 3+), and presence of
Babinski reflex on the right toe. The patient is unable to move her right upper extremity at all, but the right lower extremity can
move a little, but with apparent severe weakness. Furthermore, the patient is unresponsive to pain and light touch sensation on

Prepared by: Arisa G. Takagi, PTRP, PT

 the right UE, and has decreased sensation as to pain and light touch on the right LE (described as 50% deficit as compared to
the left side). Because of these findings, coordination is impossible to assess.

Guide Questions
1. What are the neurologic signs and symptoms of your patient #1?
 Agitation
 Wernicke’s Aphasia
 Broca’s Aphasia
 Hyperreflexia
 Babinski reflex (right toe)
 Right UE Paralysis
 Right LE Muscle Weakness
 Impaired Sensation (pain and light touch)
 Right Homonymous Hemianopia
 Increase in muscle tone
 Right-sided facial droop

2. What is the most likely cerebral hemisphere that is affected? Justify.

The left cerebral hemisphere functions in spoken and written language, and one of the most noticeable symptoms of
the patient is aphasia or difficulty in speaking and comprehension. Another symptom that confirms a damage on the
left cerebral hemisphere is the impaired motor movements in the right side of the patient’s body. Examples of these
are, Right UE Paralysis, Right LE Muscle Weakness, Right Homonymous Hemianopia, and Right-sided facial droop.
Due to the decussation on the pyramidal tract, the left hemisphere controls the right side of the body and vice versa for
the right hemisphere.

3. Looking at your patient’s clinical s/sx, what are the possible structures of the brain are affected? You may use a table
for justification.
Signs and symptoms Affected Area on the Brain/Lesion Function
Agitation Frontal lobe (pre-frontal) Behavior and emotions
Wernicke’s Aphasia Temporal lobe: Superior temporal Speech and language
(Wernicke’s Area) (Area 22) comprehension
Broca’s Aphasia Frontal lobe: Inferior frontal (Broca’s Motor speech production
Area) (Area 44, 45)
Hyperreflexia Cerebral cortex and brainstem (UMN) Reflexes and motor function
Babinski reflex Cerebral cortex and brainstem (UMN) Reflexes and motor function
Right UE Paralysis Left cerebral hemisphere Motor muscle movement,
reasoning, mathematical and
scientific skills, spoken and
written language
Right LE Muscle weakness Left cerebral hemisphere Motor muscle movement,
reasoning, mathematical and
scientific skills, spoken and
written language
Right side facial droop Left cerebral hemisphere Motor muscle movement,
reasoning, mathematical and
scientific skills, spoken and
written language
Impaired Sensation (pain and light Parietal lobe: Post central gyrus localization of touch,
touch) (Primary somatosensory) temperature, vibration, pain

Prepared by: Arisa G. Takagi, PTRP, PT

 sensory perception

Right Homonymous Hemianopia Thalamus (lateral geniculate nucleus) Sensory relay center (visual
information synapse)
Increase in muscle tone Basal Ganglia/Basal Nuclei (Globus Regulates muscle tone
Pallidus)
4. What are the lobes of the brain are affected based from your answers above? What is more affected, the lateral or
medial cerebral hemisphere, or are they equally affected? Justify.
The frontal lobe, the temporal lobe, and the parietal lobe are affected areas because of the symptoms of
motor speech impairment, mood change, localization impairment, and difficulty in language comprehension.
Moreover, the lateral cerebral hemisphere is equally affected as the medial hemisphere. The table shown
above suggests that the lesions on the lateral hemisphere are more involved on the motor functions of the
brain, while the medial hemisphere is more familiar with the sensory and cognitive functions of the patient’s
symptoms.

CLINICAL CASE 2: Why can’t you remember me?! Sections 1 and 2

Your next patient, patient X, is scheduled for your 10 AM PT session. This patient of yours is diagnosed to have a
benign brain tumor. He greets you good morning, and says “your facial features are moving all around your face and I can’t
remember you but I feel like I know you!” When you greeted him back, he recognized your voice and remembered you as
his Physical Therapist. You decided to reassess this patient to check for any improvements and know what specific part of
the brain is actually affected by the tumor. The patient can walk, there was no noted muscle weakness, no noted muscle
tone and reflex changes. He is able to write normally on a piece of paper her name and address, but when shown his own
writing a few minutes later, he is unable to read it. You tested his short-term memory by asking what he ate for breakfast
and what he did earlier this morning, he also wasn’t able to remember anything.

Guide Questions
1. What are the neurologic s/sx of your patient #2?
2. Looking at your patient’s clinical s/sx, what are the possible structures of the brain are affected? You may use a table
for justification.
3. Specify the possible location of the brain tumor based on the patient’s clinical manifestations. Justify

CLINICAL CASE 3: On Denial Sections 3 and 4

Your 3rd patient is already waiting for you, as you approached her, she complained that she tripped while walking on the way to the clinic. She then
says “My husband claims it’s because of my stroke, what is he saying?! I don’t have stroke anymore, nothing’s wrong with me!”. You calmed her
down, as she is very irritable, and asked her to sit for a while checking his vital signs. Your patient complains of continued numbness and tingling on
her left arm and leg. The following findings were revealed on re-examination: (1) mild weakness of the left leg and left arm, (2) when asked to write or
draw a clock, she moved the pen in the air off to the right of the page (see drawing below) (3) You also showed her this picture (see photo below),
and only saw the curtains and the woman on the right, (4) when asked to hold objects on her hand, she has inability to identify the comb, key, and
pen with closed eyes, but can do so when eyes are opened, and (5) when asked to don and doff her socks and shoes, she is unable to perform it as
of the moment, but claims that she can do it sometimes at home.

Prepared by: Arisa G. Takagi, PTRP, PT

 Guide Questions
1. What are the neurologic signs and symptoms of your patient #3?
2. What is the most likely cerebral hemisphere that is affected? Justify.
3. Looking at your patient’s clinical s/sx, what are the possible structures of the brain are affected? You may use a table
for justification.
4. What are the lobes of the brain are affected based from your answers above?
5. Why do you think is the PT very cautious in his treatment of this certain patient as compared to the previous ones?
What must be the treatment strategy for this patient? Choose between the two and justify
a. Focus on giving verbal or written instructions
b. Focus on providing visual and tactile cues, the PT may use mirrors and demonstrations

CLINICAL CASE 4: Split Sections 3 and 4

Another new patient today came in, your 4 th patient, came with difficulty walking as manifested by her preference being brought
to the clinic using her wheelchair. You looked at her medical chart and saw that the diagnosis is “CVA due to atrial fibrillation”.
This patient complains of paralysis on both the right UE and LE, there is noticeable right facial droop. Motor examination reveals:
increase in muscle tone of the right upper and lower extremities, increased reflexes on the right side (hyperreflexia, 3+), and
presence of Babinski reflex on the right toe. During the rest of your neurologic examination, your patient can recall almost all
information, can speak without difficulty, and has no noted sensory or visual deficit except for one: When you placed a pen on
both the left then the right hand after, there was inability, with closed eyes, to identify verbally an object held in the left hand.
However, the patient was able to identify the pen verbally when placed on the right.

Guide Questions
1. What are the neurologic signs and symptoms of your patient?
 Paralysis of the right side of the body
 Right facial droop
 Increase in muscle tone
 Hyperreflexia
 Babinski reflex
 Agnosia
2. Looking at your patient’s clinical s/sx, what are the possible specific structures of the brain are affected? You may use
a table for justification.
3. Which is affected: lateral cerebral hemisphere, medial cerebral hemisphere, or none?
4. Based from your answers above, and from your own clinical analysis of your patient’s s/sx, which is most likely
affected? Justify.
a. Cerebral cortex
b. Subcortical white matter
c. Basal ganglia
The subcortical white matter would be the most affected among the choices. Looking at the patient’s
symptoms, the lesions are both of the left and right cerebral hemisphere. Thus, we can assume that
there is an involvement of the corpus callosum which is a commissural tract that connects both the left
and right hemisphere, additionally it is also a white matter below the cortex. Therefore, a damage on
the corpus callosum would be a reason for having some impairment symptoms lesioned on both sides
of the brain.

Prepared by: Arisa G. Takagi, PTRP, PT

 References

Bailey, R.(2020) Corpus Callosum and Brain Function. Retrieved from: https://www.thoughtco.com/corpus-callosum-
anatomy-373219

Emos MC, Rosner J. (2020). Neuroanatomy, Upper Motor Nerve Signs. https://www.ncbi.nlm.nih.gov/books/NBK541082/

Brodmann Areas. (2020). KenHub website: Retrieved from https://www.kenhub.com/en/library/anatomy/brodmann-areas

Bui T, M Das J. (2020). Neuroanatomy, Cerebral Hemisphere. https://www.ncbi.nlm.nih.gov/books/NBK549789/

Splittgerber, R. (2019). Snell’s Clinical Neuroanatomy, 8th edition. Philadelphia: Wolters Kluwer.

Cerebellum. (2020). Retrieved from: https://www.amboss.com/us/knowledge/Cerebellum

Knierim Ph.D,, J.(n.d.) Chapter 5: Cerebellum. Retrieved from:

https://nba.uth.tmc.edu/neuroscience/m/s3/chapter05.html#:~:text=Cerebrocerebellum.,the%20VL%20thalamus%20(efferents).

Prepared by: Arisa G. Takagi, PTRP, PT