Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #18

Date of Consultation: 11-9-1979


This 69-year-old black male retired gardener was referred for neurological consultation for evaluation of left shoulder and left upper limb pain and paresthesias.  The patient presented a very complex medical history, which is summarized as follows.  In October 1976, the patient presented with the onset of hoarseness and hemoptysis.  Evaluation revealed a left vocal cord paralysis and a 50 per cent occlusion of the left mainstem bronchus.  Biopsy revealed no evidence of tumor, but eventually the patient received radiation treatment to the left mainstem bronchus with improvement of his vocal cord paralysis.

In the fall of 1977, the patient noted left shoulder pain and left upper anterior chest pain.  This pain was mainly aching in nature but occasionally was described as a sharp, shooting pain in the upper anterior chest, left shoulder, left axilla, and medial aspect of the left arm as far distally as the elbow.  In mid-summer of 1979, the patient noticed that his left upper limb and the left side of his face were no longer sweating, although the right side of his face continued to sweat normally.  Around the same time, the aching and sharp, shooting nature of the pain mentioned above seemed to change to a disagreeable burning sensation, and that symptom persisted unchanged to the date of consultation.  The patient denied any weakness or clumsiness in the left upper limb at the time of initial consultation. 


Mental Status Exam:  Intact.  There was no hoarseness or dysarthria present.

Cranial Nerves:  Cranial nerve examination was normal except for the following.  There was a 1 mm ptosis of the left eyelid and a 1 mm miosis of the left pupil.  External ocular movements were full, and there was no nystagmus or diplopia.

Motor System:  There was no evidence of focal muscular atrophy except in the left forearm.  Measurement of the circumference of the forearms revealed the left forearm to be 1.5 cm smaller than the right.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal in all 4 limbs; although there was a slight suggestion of weakness in the distal muscles of the left upper limb, specifically involving finger flexion, finger abduction, and abduction of the thumb and little finger.

Reflexes:  Deep tendon reflexes were 3/4 in the right upper limb and both lower limbs.  In the left upper limb, the biceps jerk was also 3/4, but the triceps jerk was 2/4, and the finger jerk was 1/4.  There was a positive Hoffman’s reflex on the right, but this was not present on the left.  Plantar reflexes were flexor bilaterally. 

Sensory System:  Sensory examination was normal in all 4 limbs, except for diminished appreciation of pinprick and light touch in the medial aspect of the left arm between the shoulder and the elbow. 

Cerebellar Function:  Intact.

Gait and Stance:  Intact.

Head and Neck Exam:  Intact, except for a suggestion of diminished sweating on the left side of the face and the left upper limb.


1.  Is there evidence of spinal cord involvement in this case and, if so, at what level?

2.  Is there evidence of dorsal or ventral root involvement or spinal nerve involvement in this case, and, if so, what is the level(s) of the involvement?

3.  Is there evidence of brachial plexus or peripheral nerve involvement in this case, and, if so, how would you differentiate between the two?  What evidence is there to support one or the other site of lesion in this case?

4.  Is there evidence of autonomic nervous system involvement in this case?  If so, what signs and symptoms support this conclusion?

5.  What is the localizing significance of the left vocal cord paralysis, what nerve was involved in producing that sign, and what was the most likely anatomical location of the pathologic process causing this problem? 

6.  What is the localizing significance of the left sided ptosis, miosis, and absence of sweating (anhidrosis), and what specific structures are involved by the pathologic process to produce these signs?  This combination of signs and symptoms constitutes a classic neurologic syndrome.  What is the name of that syndrome?

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

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

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