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Lesion localization · Neuroanatomy · INBDE Patient Cases

Brain Regions INBDE Patient Cases

By Dr. Isaac Sun, DDS

12 ADA INBDE-format patient cases on brain regions. Each case is a shared patient box (chief complaint, history, medications, allergies, exam) followed by linked multiple-choice questions with full distractor explanations. Practice the way the real exam is structured.

12 patient cases60 linked questionsADA INBDE formatFull distractor explanations

Twelve ADA INBDE-format patient cases on brain regions and lesion localization: the cerebral cortex (frontal, parietal, temporal, occipital lobes), the basal ganglia (substantia nigra, caudate, subthalamic nucleus), the cerebellum, the hippocampus and limbic system, the prefrontal cortex, the ventricular and cerebrospinal fluid system, and the optic chiasm. Topics include acute middle cerebral artery stroke with Broca's aphasia, Wernicke's aphasia, hemispatial neglect, anterior cerebral artery leg weakness with abulia, posterior cerebral artery homonymous hemianopia, Parkinson's disease, Huntington's chorea, cerebellar ataxia, hippocampal amnesia in early Alzheimer's disease, frontal lobe disinhibition, normal pressure hydrocephalus, and a pituitary adenoma causing bitemporal hemianopia with the oral signs of acromegaly.

Case Coverage Map
What each case is testing
Right-sided droop and garbled speech mid-appointment:
Left (dominant) MCA stroke, Broca's aphasia, forehead-sparing UMN sign, chairside stroke response.
Fluent but nonsensical speech at recall:
Wernicke's aphasia (dominant temporal lobe), comprehension vs fluency, arcuate fasciculus.
Ignoring the left side after a stroke:
Right (non-dominant) parietal hemispatial neglect, neglect vs hemianopia, neglected-side hygiene.
Leg-predominant weakness and apathy:
ACA stroke, medial homunculus leg territory, abulia, transfer and fall risk.
Bumping into objects on one side:
PCA occipital stroke, homonymous hemianopia with macular sparing, approach from the intact field.
Resting tremor and rigidity in a denture patient:
Parkinson's disease (substantia nigra), medication timing, orthostatic hypotension, sialorrhea.
Involuntary writhing movements with a family history:
Huntington's chorea (caudate, autosomal dominant), hemiballismus contrast, stabilization for care.
Clumsy hand and unsteady gait:
Cerebellar lesion, ipsilateral intention tremor, vermis vs hemisphere, powered-brush hygiene.
Repeating questions and missing appointments:
Hippocampal anterograde amnesia (early Alzheimer's), capacity and consent, anticholinergic xerostomia.
Personality change after a head injury:
Prefrontal cortex disinhibition (Phineas Gage pattern), decision-making capacity, spared motor exam.
Shuffling gait, incontinence, and confusion:
Normal pressure hydrocephalus (communicating), wet-wacky-wobbly triad, fall risk and VP-shunt prophylaxis.
Losing peripheral vision with a changing bite:
Pituitary adenoma compressing the optic chiasm, bitemporal hemianopia, oral signs of acromegaly.
Patient case: Sudden right-sided droop and garbled speech mid-appointment
0 of 5 answered, 0 correct
Patient
Male, 67 years old, right-handed
Chief Complaint
"He was fine a minute ago, now his face is drooping and he can't get his words out," his daughter says.
Background and/or Patient History
  • Hypertension and atrial fibrillation
  • Symptoms began mid-way through a crown preparation
  • Right face and arm weakened over 1 to 2 minutes
  • Speech is effortful and sparse; he appears to understand questions
  • Reports stopping his anticoagulant two weeks ago
Allergies
NKDA
Medications
  • Lisinopril 20 mg daily
  • Metoprolol 50 mg twice daily
Current Findings
  • Right facial droop that spares the forehead
  • Right arm drift; right leg much less affected
  • Non-fluent, halting speech; follows simple commands
  • Last known well: 5 minutes ago
  1. Question 1
    Easy
    Where is the lesion most likely located?
  2. Question 2
    Moderate
    His effortful, halting speech with preserved comprehension is best described as:
  3. Question 3
    Moderate
    The fact that his forehead is spared on the weak side indicates:
  4. Question 4
    Easy
    The most appropriate immediate action is to:
  5. Question 5
    Hard
    Why does this stroke affect the face and arm more than the leg?

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Patient case: Fluent but nonsensical speech at a recall visit
0 of 5 answered, 0 correct
Patient
Female, 72 years old, right-handed
Chief Complaint
"Oh the weather table runs nicely under the going," she answers cheerfully when asked how she is doing.
Background and/or Patient History
  • Hypertension and a prior transient ischemic attack
  • Arrived alone for a routine recall; front desk noticed her speech was off
  • Speaks fluently with normal rhythm, but the words are jumbled
  • Does not follow "open wide" or "turn your head" commands
Allergies
NKDA
Medications
  • Amlodipine 5 mg daily
  • Aspirin 81 mg daily
Current Findings
  • Fluent, paraphasic, meaningless speech
  • Comprehension poor; cannot follow simple commands
  • No obvious facial droop or limb weakness
  1. Question 1
    Moderate
    Which area is most likely affected?
  2. Question 2
    Easy
    This pattern is called:
  3. Question 3
    Moderate
    The single feature that separates her aphasia from Broca's aphasia is:
  4. Question 4
    Moderate
    The most appropriate response is to:
  5. Question 5
    Hard
    The fiber bundle connecting Wernicke's and Broca's areas, whose isolated injury causes a repetition deficit (conduction aphasia), is the:

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Patient case: Ignoring the left side after a stroke
0 of 5 answered, 0 correct
Patient
Male, 70 years old, right-handed
Chief Complaint
His wife says, "Since his stroke he shaves only the right side of his face and leaves all the food on the left of his plate."
Background and/or Patient History
  • Right hemisphere stroke six weeks ago
  • Now presenting for overdue dental care
  • Left-sided food pocketing and heavy plaque noticed on the left
  • Does not turn toward people who address him from his left
Allergies
Penicillin
Medications
  • Atorvastatin 40 mg daily
  • Clopidogrel 75 mg daily
Current Findings
  • Inattention to the left side of space
  • Heavy left-sided food debris and plaque; left buccal mucosa coated
  • Mild left facial droop sparing the forehead; mild left arm drift
  • Insists nothing is wrong with his left side
  1. Question 1
    Moderate
    Where is the responsible lesion?
  2. Question 2
    Easy
    This finding is called:
  3. Question 3
    Moderate
    Why is his language intact despite a large cortical stroke?
  4. Question 4
    Hard
    How does neglect differ from a homonymous hemianopia?
  5. Question 5
    Moderate
    The most useful dental adjustment for this patient is to:

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Patient case: Leg-predominant weakness and loss of initiative after a stroke
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Patient
Female, 64 years old
Chief Complaint
Her son reports, "Her right leg keeps giving out, but her arm and face seem fine, and she just sits there with no motivation."
Background and/or Patient History
  • Recent stroke; presenting for clearance before an extraction
  • Right leg weakness noticeably greater than arm weakness
  • Minimal facial involvement
  • Markedly apathetic and slow to start any activity
Allergies
NKDA
Medications
  • Hydrochlorothiazide 25 mg daily
Current Findings
  • Right leg weakness greater than right arm weakness
  • Abulia (decreased initiative and spontaneity)
  • A grasp reflex is present
  1. Question 1
    Moderate
    Which artery territory is most likely involved?
  2. Question 2
    Moderate
    Why is the leg weaker than the arm in this stroke?
  3. Question 3
    Moderate
    Her apathy and lack of initiative (abulia) reflect damage to the:
  4. Question 4
    Easy
    Compared with an MCA stroke, an ACA stroke characteristically:
  5. Question 5
    Moderate
    A practical dental consideration for this patient is:

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Patient case: Bumping into objects on one side after a stroke
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Patient
Male, 68 years old
Chief Complaint
"I keep knocking over things on my left, and I didn't even see the assistant walk in from that side."
Background and/or Patient History
  • Recent stroke confirmed in the occipital region
  • Misses objects in the left visual field
  • Normal strength and normal speech
  • Aware of the deficit and turns his head to compensate
Allergies
NKDA
Medications
  • Aspirin 81 mg daily
  • Lisinopril 10 mg daily
Current Findings
  • Left homonymous hemianopia with macular sparing
  • No limb weakness, no aphasia, no neglect
  • Turns head left to scan the missing field
  1. Question 1
    Moderate
    Where is the lesion?
  2. Question 2
    Easy
    His visual deficit is best described as:
  3. Question 3
    Moderate
    Why is his strength preserved?
  4. Question 4
    Hard
    How does his hemianopia differ from hemispatial neglect?
  5. Question 5
    Moderate
    The most helpful chairside adjustment is to:

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Patient case: Resting tremor and rigidity in a denture patient
0 of 5 answered, 0 correct
Patient
Male, 74 years old
Chief Complaint
"My hands shake when they are just resting, and I can't keep my dentures or my teeth clean anymore."
Background and/or Patient History
  • Parkinson's disease for six years
  • Pill-rolling tremor that improves when he reaches for something
  • Slow movements, stiffness, and a stooped posture
  • Drooling and difficulty with oral hygiene
Allergies
NKDA
Medications
  • Carbidopa-levodopa four times daily
  • Pramipexole
Current Findings
  • Resting pill-rolling tremor; cogwheel rigidity
  • Masked facies (hypomimia) and soft, monotone speech
  • Sialorrhea and heavy plaque from poor mechanical control
  • Mild orthostatic symptoms on standing
  1. Question 1
    Moderate
    The degeneration responsible for his motor signs is in the:
  2. Question 2
    Moderate
    His tremor is best characterized as:
  3. Question 3
    Moderate
    The best time to schedule his dental treatment is:
  4. Question 4
    Moderate
    When ending the appointment, the key autonomic precaution is to:
  5. Question 5
    Hard
    His sialorrhea and poor plaque control most directly increase the risk of:

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Patient case: Involuntary writhing movements with a family history
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Patient
Female, 45 years old
Chief Complaint
"I can't hold still in the chair, these movements just happen, and my father had the exact same thing."
Background and/or Patient History
  • Father affected by the same progressive movement disorder
  • Two years of worsening involuntary movements
  • Irritability, depression, and early memory complaints
  • Difficulty keeping her mouth open for examination
Allergies
NKDA
Medications
  • Tetrabenazine
  • Sertraline
Current Findings
  • Continuous, dance-like involuntary movements (chorea)
  • Cannot sustain mouth opening or tongue protrusion
  • Cognitive and mood changes noted by family
  1. Question 1
    Moderate
    The structure that degenerates in this disease is the:
  2. Question 2
    Moderate
    The inheritance pattern is:
  3. Question 3
    Easy
    Her involuntary movements are classified as:
  4. Question 4
    Moderate
    As her chorea and swallowing progressively worsen, the main dental concern becomes:
  5. Question 5
    Moderate
    A safe and practical way to deliver her dental care is to:

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Patient case: A clumsy hand and an unsteady, wide gait
0 of 5 answered, 0 correct
Patient
Male, 60 years old
Chief Complaint
"My right hand overshoots when I reach for things, and I walk like I'm drunk even when I'm completely sober."
Background and/or Patient History
  • Long history of heavy alcohol use
  • Right-hand clumsiness that worsens as he reaches a target
  • Wide-based, staggering gait
  • Normal strength and normal sensation
Allergies
NKDA
Medications
  • Thiamine
  • Folic acid
Current Findings
  • Right-sided intention tremor and dysmetria on finger-to-nose
  • Dysdiadochokinesia on rapid alternating movements
  • Wide-based gait; normal power and reflexes
  1. Question 1
    Moderate
    His right-sided limb signs localize to the:
  2. Question 2
    Easy
    His tremor, which worsens as his hand nears the target, is a(n):
  3. Question 3
    Hard
    Why are cerebellar signs ipsilateral to the lesion?
  4. Question 4
    Moderate
    If instead his main problem were a wide-based gait and truncal instability with normal limb coordination, the lesion would be in the:
  5. Question 5
    Moderate
    The most useful oral-health recommendation for him is to:

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Patient case: Repeating questions and forgetting the visit entirely
0 of 5 answered, 0 correct
Patient
Female, 78 years old
Chief Complaint
Her daughter explains, "She asks the same questions every few minutes and already forgot she came in today."
Background and/or Patient History
  • Two-year history of progressive short-term memory loss (early Alzheimer's disease)
  • Cannot form new memories; remote memories are better preserved
  • Repeatedly misses appointments and forgets oral hygiene instructions
  • Accompanied by her daughter, who manages her care
Allergies
NKDA
Medications
  • Donepezil
  • Oxybutynin for overactive bladder
Current Findings
  • Anterograde amnesia; disoriented to date and place
  • Long-term and procedural memory relatively intact
  • Generalized plaque and several new root-surface caries
  1. Question 1
    Moderate
    The structure most responsible for her inability to form new memories is the:
  2. Question 2
    Moderate
    Her inability to form new memories while older memories persist is called:
  3. Question 3
    Moderate
    Which type of memory is typically spared early in her disease?
  4. Question 4
    Hard
    Regarding consent and instructions, the best approach is to:
  5. Question 5
    Hard
    Her new root caries are most directly worsened by which medication-related factor?

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Patient case: Personality change and poor judgment after a head injury
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Patient
Male, 52 years old
Chief Complaint
His wife says, "Since his accident he is crude, impulsive, and makes terrible decisions; he is not the man I married."
Background and/or Patient History
  • Frontal head injury one year ago
  • Marked personality change: disinhibition, impulsivity, poor judgment
  • Apathy alternating with inappropriate jokes
  • Intact strength, speech, and memory for events
Allergies
NKDA
Medications
  • None
Current Findings
  • Socially inappropriate and impulsive in the operatory
  • Normal motor exam and fluent speech
  • Poor planning and limited insight into his behavior
  1. Question 1
    Moderate
    Which region is most likely damaged?
  2. Question 2
    Moderate
    The best way to manage his behavior during treatment is to:
  3. Question 3
    Moderate
    The functions most impaired in him are:
  4. Question 4
    Hard
    Regarding consent for elective treatment, you should:
  5. Question 5
    Moderate
    Why is his motor examination normal despite a frontal lobe lesion?

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Patient case: Shuffling gait, incontinence, and confusion in an elderly patient
0 of 5 answered, 0 correct
Patient
Male, 76 years old
Chief Complaint
"My feet feel stuck to the floor when I walk, I have been forgetful, and I have had some bladder accidents."
Background and/or Patient History
  • Several months of progressive gait difficulty
  • Cognitive slowing and urinary incontinence
  • Imaging shows ventricular enlargement out of proportion to cortical atrophy
  • Came in with his wife for denture adjustment
Allergies
NKDA
Medications
  • Atorvastatin 20 mg daily
Current Findings
  • Magnetic, shuffling, wide-based gait
  • Cognitive slowing on conversation
  • Reported urinary incontinence
  1. Question 1
    Moderate
    This triad of gait difficulty, cognitive decline, and incontinence with enlarged ventricles is most consistent with:
  2. Question 2
    Moderate
    His clinical triad is classically remembered as:
  3. Question 3
    Easy
    His shuffling, unsteady gait most directly creates which dental-office risk?
  4. Question 4
    Moderate
    Why is recognizing this syndrome important?
  5. Question 5
    Moderate
    Regarding his ventriculoperitoneal (VP) shunt and dental treatment:

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Patient case: Losing peripheral vision on both sides with a changing bite
0 of 5 answered, 0 correct
Patient
Female, 48 years old
Chief Complaint
"I keep missing things off to both sides, I clipped both door frames driving, and my jaw and hands seem to be getting bigger."
Background and/or Patient History
  • Gradual loss of peripheral vision on both sides
  • Enlarging jaw with new spacing between the teeth and an ill-fitting denture
  • Increasing ring and glove size; deepening voice
  • Headaches over several months
Allergies
NKDA
Medications
  • None
Current Findings
  • Bitemporal hemianopia on confrontation visual fields
  • Mandibular prognathism with new interdental spacing (diastemata)
  • Macroglossia and enlarged soft tissues
  1. Question 1
    Moderate
    Her bitemporal visual field loss localizes to compression of the:
  2. Question 2
    Hard
    Bitemporal hemianopia occurs because the chiasm carries the:
  3. Question 3
    Moderate
    The most likely lesion compressing the chiasm from below is a:
  4. Question 4
    Hard
    Her enlarging jaw, new tooth spacing, and macroglossia suggest the adenoma is secreting:
  5. Question 5
    Moderate
    Her bitemporal hemianopia differs from a homonymous hemianopia in that it reflects a lesion:

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