The swallow comes first — lateral medulla
| Patient | 61M, acute phase |
|---|---|
| Lesionbrainstem territory, moderate | |
| Severity | NIHSS 6 |
| Days since onset | 2 |
| Before the strokeIndependent; bus driver, amateur bowls player. | |
| Also on the chart | Hypertension; Smoker |
| PrecautionsNothing by mouth until swallow screen passed; Fall risk — veers right | |
Test yourself
He wants water. What happens before anything crosses his lips?
The teaching
The Wallenberg case is two lessons in one patient: the swallow screen gates everything oral, and crossed sensory signs with ataxia are a brainstem syndrome — not a vestibular one. The family conversation protects the precaution by explaining it, because an unexplained nil-by-mouth is a rule relatives break.
- Wet voice, desaturation or fever — aspiration until proven otherwise
Read next
The full sequence
This page carries the case’s first decision. The full sequence — every decision, the five-domain examination, and the debrief that grades you — is in the drill, and the library is included with membership.
Sources on this page: Winstein CJ et al. Stroke. 2016 · Winstein CJ et al. Stroke. 2016. Milne SC et al. J Physiother. 2017