Dudley, a 55-year-old right-handed hypertensive man, developed slurred speech and weakness of his right arm and leg shortly after arising one morning.
Examination showed him to be alert with dysarthria. The pupils were both 2mm and reactive to light. Extraocular movements were full. Upbeating nystagmus was seen in the primary position of gaze (i.e., straight-ahead position). The face was symmetric. The tongue deviated to the left on protrusion. There was moderate weakness of the right arm and leg. The deep tendon reflexes were increased on the right and there was a right Babinski response. On sensory testing, there was loss of proprioception in the right hand and foot, as well as loss of appreciation of vibration in the right limbs.
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