Case History #1

Date of Consultation: 6-26-1985

HISTORY OF PRESENT ILLNESS:

This 74-year-old right-handed white female retired clerk was admitted to the hospital on 6-3-85 by an orthopedic surgeon for a left total hip replacement due to osteoarthritis.  The patient did well postoperatively and was ready for discharge until 6-20-85, when she was discovered to have left lower limb deep vein thrombosis.  She was placed on heparin and was doing well until 6-23-85, when she had the sudden onset of left groin pain and tenderness.  This was felt to be due to extension of her thrombophlebitis, and she was given an extra dose of heparin.  Unfortunately, a nursing error resulted in her getting 10 times the dose of heparin that was ordered.  The patient’s PTT shot up to 81, and she developed the acute onset of left lower quadrant abdominal pain and simultaneously noted numbness and tingling of the left thigh for the first time.  From that point on, the patient noticed numbness in the anterior and medial thigh on the left side as well as a numbness of the anteromedial lower leg from the knee to the ankle.  She also noticed some weakness in flexion of the thigh at the hip joint and extension of the leg at the knee joint.  A neurological consultation was obtained at this point.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact. 

Cranial Nerves:  Intact.

Motor System:  There were no areas of focal muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal in both upper limbs and in the right lower limb.  In the left lower limb, muscle power was normal distally with 5/5 strength noted in the dorsiflexors and plantar flexors of the ankle, knee flexors, hip adductors and abductors, and hip extensors.  Hip flexion on the left was rated at 3/5, and knee extension on the left was 2/5.

Reflexes:  Deep tendon reflexes were 2/4 and equal in the upper limbs.  Knee jerks were 2/4 on the right and absent on the left.  Ankle jerks were absent bilaterally.  Plantar reflexes were flexor bilaterally.

Sensory System:  Sensory examination was normal in both upper limbs and the right lower limb.  In the left lower limb, there was decreased appreciation of light touch and pinprick in the anterior, medial, and lateral thigh regions.  At times, there was a hyperpathic or exaggerated response to pinprick.  There was also decreased appreciation of light touch and pinprick in the anteromedial aspect of the leg. 

Cerebellar Function:  Intact.

Gait and Stance:  Not tested.