Case History #165

Date of Admission: 12-19-2009

HISTORY OF PRESENT ILLNESS:

This 48-year-old right-handed white female was admitted to the hospital for left-sided numbness, tingling, and clumsiness.  The patient is known to have diabetes and hypertension. 

Three days prior to admission, the patient had an argument with her son, after which she did not feel well and felt somewhat shaky.  She took her medications and went to bed.

When she woke up the next morning, she noted numbness and tingling on the left side of the face, arm, and leg, as well as a heavy feeling of the left arm and an inability to use the left arm and leg normally.  The symptoms did not improve, so she came to the emergency room and was admitted to the neurology service for further evaluation.

The patient’s neurologic review of systems, aside from the above, was remarkable only for some unsteadiness of gait.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was normal except for the following.  Sensory testing of the face revealed diminished appreciation of light touch and pinprick on the left side of the face.  No facial weakness was present.

Motor System:  There were no areas of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all four limbs.  Muscle power was normal bilaterally.  There were no involuntary movements.  When the patient closed her eyes and held her arms extended in front of her, the left arm drifted upward and downward slowly. 

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

Sensory System:  Sensory examination was entirely normal on the right side.  On the left side, there was decreased appreciation of pinprick, light touch, vibration, and joint position sense in both the upper and lower limbs. 

Cerebellar Function:  Cerebellar tests were performed normally bilaterally, although there was some difficulty with rapid alternating and rapid repetitive movements with the left hand. 

Gait and Stance:  Regular gait was performed normally.  The patient was able to walk on her heels and toes.  However, she was slightly unsteady with tandem gait.  The Romberg test was also difficult, and she tended to lose her balance with her eyes closed. 

Questions:

1.  What is the localizing significance of the fact that essentially all sensory modalities are involved in this case, as opposed to the sparing of one or more of the modalities?
           

2.  What is the meaning or significance of this patient’s difficulty with left upper limb coordination?
            

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

4.  Indicate the specific structures possibly involved by the pathologic process.
            

5.  This patient’s signs and symptoms constitute a classic neurologic syndrome.  What is the name of that syndrome, and what is its usual cause?
            

6.  In general, what type of pathologic process do you think is involved in this case?
            

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