Case History #193
Date of Admission: 11-5-2011
HISTORY OF PRESENT ILLNESS:
This 60-year-old right-handed African-American female was admitted to the hospital for evaluation of left lower limb weakness. The patient is known to have hypertension, atrial fibrillation, and cocaine abuse. Two days prior to admission, the patient noted the sudden onset of left lower limb weakness as she was getting into bed. At that point, the left lower limb was essentially paralyzed, and she fell to the ground. There was some degree of left upper limb weakness as well, but this resolved after a few hours. She came to the emergency room two days later because she was having difficulty walking due to the persistent left lower limb weakness. She was admitted to the Neurology Service for further evaluation and management.
NEUROLOGICAL EXAMINATION:
Mental Status Exam: Intact.
Cranial Nerves: Cranial nerve examination was entirely normal.
Motor System: There were no areas of focal or generalized muscular atrophy. There were no fasciculations. Muscle tone was normal in the right upper and lower limbs and in the left upper limb. In the left lower limb, muscle tone was mildly increased. Muscle power testing was normal (5/5) in the right upper and lower limbs and in the left upper limb. In the left lower limb, muscle power was moderately weak (3/5) proximally and mildly weak (4/5) distally.
Reflexes: Deep tendon reflexes were equal and symmetric in all 4 limbs, and the plantar reflexes were flexor bilaterally.
Sensory System: The patient perceived all modalities of sensation, including cortical sensations, normally in all 4 limbs.
Cerebellar Function: The patient performed all cerebellar tests normally in all 4 limbs, except for slowness of movement in the left lower limb due to weakness.
Gait and Stance: Not tested
Questions
1. Is there evidence of peripheral nervous system involvement in this case, and, if so, what is the level(s) of that involvement?
2. Is there evidence of spinal cord involvement in this case and, if so, at what level?
3. Could this patient’s signs and symptoms be localized to any other place in the central nervous system? If so, what is the precise localization of her neurologic lesion, including the side of involvement? Indicate the specific structure(s) involved by this lesion.
4. In general, what type of pathologic process is involved in this case? If vascular, what vessel is involved?
5. What diagnostic procedure(s) would you undertake at this point?