Case History #196

Date of Admission: 7-27-2012

HISTORY OF PRESENT ILLNESS:

This 73-year-old right-handed retired African-American female was admitted to the hospital for the acute onset of right-sided weakness.  She is known to have hypertension, and she was diagnosed with chronic myelocytic leukemia in 2005 and right-sided breast cancer in 1984.  At 1:00 p.m. on the day of admission, the patient awoke from a nap and noted weakness of her right arm and right leg.  She did not notice any numbness, tingling, or loss of sensation, and she experienced no other neurologic symptoms.  By the time she reached the emergency room, her right arm was improving slightly, but she was still having difficulty walking due to right lower limb weakness. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was entirely normal, except for mild flattening of the right nasolabial fold and a slight lag of the right lower face when the patient smiled or grimaced.

Motor System:  There were no areas of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal (5/5) on the left side.  Strength was mildly diminished (4/5) in the right upper and lower limbs.  Rapid repetitive movements in the right hand were slowed. 

Reflexes:  Deep tendon reflexes were equal and symmetric, and the plantar reflexes were flexor on the left and equivocal on the right.

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

Cerebellar Function:  Cerebellar tests were performed normally in the left upper and lower limbs.  In the right upper and lower limbs, finger-to-nose and heel-to-shin testing revealed mild dysmetria, dyssynergia, and an intention tremor.  Rapid alternating movements were performed dysrhythmically in the right upper and lower limbs.

Questions

1.  Considering the patient’s history and physical examination, how precisely can the neurologic lesion be localized in this case?          

2.  Indicate the level of the neurologic lesion in this case as precisely as possible and the structures involved by the pathologic process.  If precise localization is not possible, list as many levels or structures as you can that might produce the same clinical picture.

Signs or Symptoms                           Site of Lesion               
Weakness of RUE & RLE,                       
mild R UMN facial weakness
                                  
RUE & RLE neocerebellar signs          
(dysmetria, impaired finger-to-nose,                          
heel-to-shin, dyssynergia, 
intention tremor,
dysdiadochokinesis)             

3.  Discuss the “localization of the lesion” in this case.

4.  The findings in this case represent a classic neurologic syndrome.  What is the name of that syndrome, and what is its usual cause? 

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

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