Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #191

Date of Admission: 2-14-2011


This 37-year-old right-handed white female, who is medically disabled due to multiple medical problems, was admitted to the hospital for sensory findings in all four limbs.  About 3 months prior to admission, the patient noted numbness and tingling in both hands, which also soon became noticeable in her feet bilaterally.  These symptoms ascended in the lower limbs to just above the knees and in the upper limbs to just above the wrists bilaterally.  She noted no bowel or bladder difficulties.  About two weeks prior to admission, she began to have pain in her feet and hands.  These sensory symptoms also involved the scalp of the back of the head, but she voiced no sensory complaints involving her face.

Over the two months prior to admission, the patient noted difficulty walking, and she believed that difficulty was because she did not know where her feet were.  She also noted a tendency to lose her balance, when she closed her eyes to wash her hair in the shower.  However, she had not fallen.  The overall course of these symptoms was one of slow progression over the past two to three months.  She denied any other neurologic symptoms aside from the above.


Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was entirely normal.

Motor System:  There was no evidence of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all four limbs.  Muscle power was normal (5/5) in all four limbs with her eyes open.  With her eyes closed, a very mild weakness (4+/5) was noted.

Reflexes:  Deep tendon reflexes were equal and symmetric in all four limbs, although her ankle jerks were hypoactive bilaterally.  Plantar reflexes were mute bilaterally. 

Sensory System:  Distal blunting to pinprick, light touch, and temperature was present in all four limbs, with the sensations normalizing at about the knee in the lower limbs and mid-forearm in the upper limbs.  Vibration and joint position sense were markedly decreased in the fingers and toes bilaterally, with gradual improvement as one moved proximally.

Cerebellar Function:  The patient performed all cerebellar tests normally.

Gait and Stance:  Regular gait was performed on a wide base, and the patient took small, shuffling steps in order to maintain her balance.  Tandem gait was not attempted.  The Romberg test was positive.


1.  Considering this patient’s history and physical examination, how precisely can the neurologic lesion be localized? 
2.  Is there evidence of peripheral nervous system involvement in this case, and, if so, what is the level(s) of the involvement?  How would you characterize this peripheral nervous system involvement, if it is present?

3.  Is there evidence of spinal cord involvement in this case and, if so, at what level?  If spinal cord involvement is present, which specific structures are involved by the pathologic process? 
4.  In general, what type of pathologic process do you think is involved in this case? 

5.  What initial diagnostic studies would you undertake at this point? 
6.  This patient’s illness represents a classic neurologic syndrome.  What is the name of this syndrome, and what is its etiology?

7.  What additional diagnostic procedures would you undertake at this point? 


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