A 64-Year-Old Smoker Is Evaluated for Nagging Right Shoulder Pain

A 64-year-old smoker is evaluated for nagging right shoulder pain that radiates to the ipsilateral arm.  The patient also has weakness in the right upper extremity.  His symptoms started 2 months ago and have worsened progressively.  On neurologic examination, the patient is awake, alert, oriented, and follows commands.  He has partial right-sided ptosis with fully intact extraocular movements.  His pupils are asymmetric in dim light with 2 mm on the right and 4 mm on the left, but both are reactive to light.  The pupils become more symmetric in bright light.  The right upper extremity has 3/5 strength and absent deep tendon reflexes.  This patient's autonomic dysfunction is most likely a result of a lesion involving which of the following?

A) Autonomic ganglia
B) Brainstem
C) Cerebral cortex
D) Spinal cord
E) Subcortical grey matter
F) Vagus nerve

Correct Answer:

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