Case History #146

Date of Consultation: 11-18-2007

HISTORY OF PRESENT ILLNESS:

This 71-year-old right-handed Asian male with a past history of ulcerative colitis and hypertension was diagnosed with non-small-cell lung cancer in May of 2007.  He has known metastases to bone. 

Since May 2007, the patient has been treated with various chemotherapy regimens.  On 11-14-2007, he began a new chemotherapeutic agent. 

On 11-17-2007, the patient awoke in the morning and noted the onset of lightheadedness, wooziness, and difficulty maintaining his balance when he sat up or attempted to walk.  His oncologist admitted him to the hospital and requested a neurologic consultation for these findings. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Intact.

Motor System:  No areas of focal or generalized muscular atrophy were noted.  There were no fasciculations.  Muscle tone and power were normal in all 4 limbs.

Reflexes:  Deep tendon reflexes were equal and symmetric, and the plantar reflexes were flexor bilaterally. 

Sensory System:  Intact.

Cerebellar Function:  Heel-to-shin and finger-to-nose testing were essentially unremarkable, except for very slight dysmetria and dyssynergia with finger-to-nose testing in the right upper limb.  When the patient attempted to sit on the side of the bed, he had considerable difficulty maintaining his balance.  There was a slight tendency to fall to the right. 

Gait and Stance:  When he attempted to walk, there was dramatic lurching and instability, and he basically could not maintain a standing position.

Questions:

1.  Indicate the possible anatomical locations of the pathologic process in this case.
            

2.  Indicate the specific structures involved by the pathologic process.
            

3.  What is the term for this patient’s findings when he attempted to sit on the side of the bed?
            

4.  In general, what type of pathologic process do you think is involved in this case?  What other considerations would be in this patient’s differential diagnosis?
 

5.  What diagnostic procedure(s) would you undertake at this point?