Case History #195

Date of Admission: 6-22-2012

HISTORY OF PRESENT ILLNESS:

This 66-year-old right-handed Middle Eastern gentleman was admitted to the neurology service for evaluation of left upper limb weakness.  Two days prior to admission, the patient noted the acute onset of left upper limb weakness, as well as mild left lower limb weakness.  These symptoms did not improve, and therefore the patient came to the emergency room and was admitted to the hospital. 

The patient is not known to have hypertension, diabetes, cardiac arrhythmia, or hyperlipidemia.  Nor does he have a history of smoking in the past.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was entirely normal.

Motor System:  There were no areas of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone was normal in the right upper and lower limbs and in the left lower limb.  In the left upper limb, muscle tone was slightly diminished.  Muscle power testing was entirely normal (5/5) on the right side.  In the left upper limb, muscle power was markedly reduced throughout, being rated as 0/5 to 2/5 in different muscle groups.  In the left lower limb, muscle power was mildly reduced and rated 4/5 throughout. 

Reflexes:  Deep tendon reflexes were slightly brisker on the left, especially in the upper limb, and the plantar reflexes were flexor on the right and extensor on the left. 

Sensory System:  The patient perceived all modalities of sensation, including cortical sensations, normally in all 4 limbs.

Cerebellar Function:  The patient performed all cerebellar tests normally on the right side.  On the left side, cerebellar testing was compromised by his left-sided weakness. 

Gait and Stance:  The patient had mild difficulty walking due to left lower limb weakness.  The Romberg test was negative.  Tandem gait, walking on his heels, and walking on his toes were deferred.

Questions:

1.  Is there evidence of peripheral nervous system involvement in this case, and, if so, what is the level of that involvement?    

2.  Is the patient’s left upper limb weakness of the upper motor neuron or lower motor neuron type?       

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

4.  Could this patient’s signs and symptoms be localized to any other place in the central nervous system?  If so, what is the precise localization of his neurologic lesion, including the side of involvement?  Indicate the specific structure(s) involved by this lesion.

5.  In general, what type of pathologic process is involved in this case?  If vascular, what vessel is involved?

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