Case 150

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case History #150

Date of Consultation: 8-11-2006

HISTORY OF PRESENT ILLNESS:

This 40-year-old right-handed African-American female with a past medical history of hypertension, diabetes, and obesity was referred for neurologic evaluation because of right face pain. On 8-29-2005, the patient noted the acute onset of left hand numbness, unsteadiness, and difficulty speaking and swallowing. She went to another institution for acute diagnosis and treatment. Subsequently, she entered an inpatient rehabilitation institute. Over the next several weeks, her gait difficulties, speech problems, and swallowing difficulties gradually resolved. However, she continued to have ongoing difficulties with burning pain on the right side of the face. This pain is more or less constantly present and has not improved or deteriorated over the past year.

NEUROLOGICAL EXAMINATION:

Mental Status Exam: No deficits of orientation, speech, or memory were present. The patient’s mood was judged to be normal.

Cranial Nerves: Sensation of smell and visual acuity were not tested. Visual field and funduscopic examinations were unremarkable. External ocular movements were full without nystagmus or diplopia. Pupils were equal, round, and reactive to light. There was no ptosis present. Sensory and motor functions of the Vth cranial nerve were normal, except for decreased appreciation of pinprick on the right side of the face. There was no facial weakness. Hearing was intact bilaterally. XIth cranial nerve functions were normal. Tongue and palate appeared normal.

Motor System: Intact.

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

Sensory System: Perception of light touch, pinprick, vibration, and joint position sense was normal in all four limbs and symmetric.

Cerebellar Function: Intact.

Gait and Stance: Regular gait was performed normally, and the Romberg test was negative.

Questions

1. Indicate the specific structures that could possibly be involved by the pathologic process to produce each of the symptoms in this patient, based on the patient’s history.

a. Left hand numbness

b. Burning pain on the right side of the face

c. Unsteadiness

d. Dysarthria, dysphagia

2. How would you describe this patient’s right facial pain?

3. Indicate the specific structures that could possibly be involved by the pathologic process to produce each of the signs or symptoms in this patient, based on both the patient’s history (symptoms) and the examination (signs).

a. Ataxia, unsteadiness

b. Dysarthria, dysphagia

c. Decreased pain on the right side of the face. Burning pain on the right side of the face.

d. Left hand numbness

4. The findings in this case constitute a classic neurologic syndrome. Indicate the location of the neurologic lesion, the main structure involved in this case, and the name of the syndrome.

5. In general, what type of pathologic process do you think is involved in this case? Be as specific as possible.

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

Answers