Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #197

Date of Consultation: 6-7-1989


This 43-year-old right-handed white female was admitted to the hospital on 6-7-1989 by her gastroenterologist for fever, cough, and septic shock.  She is known to suffer from multiple medical problems, including a three-month history of weight loss.  Neurological consultation was requested to evaluate right hand symptoms.

The patient reported a 3 to 6 month history of gradually progressive numbness and tingling involving the fourth and fifth digits of the right hand.  She also noted progressive right hand weakness and clumsiness, and she is no longer able to write with her right hand. 


Mental Status Exam:  Intact. 

Cranial Nerves:  Intact.

Motor System:  There were no areas of focal muscular atrophy, except for moderate atrophy of the right hypothenar eminence muscles and the dorsal interosseous muscles.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal in all four limbs except for the right hand, as follows.  Abduction and flexion of the fifth digit and finger abduction and adduction were rated at 3 to 4/5.  Thumb flexion and abduction, finger flexion and extension, grip strength, and wrist flexion and extension were all rated at 5/5. 

Reflexes:  Deep tendon reflexes were 2/4 and equal in all four limbs.  Plantar reflexes were flexor bilaterally.

Sensory System:  Sensory examination was normal in all four limbs, except for the right hand.  In the right hand, there was decreased appreciation of light touch and pinprick in the anterior (palmar) aspect of the medial half of the fourth finger and the entire fifth finger, as well as the medial aspect of the palm.  Tapping over the right ulnar nerve behind the medial epicondyle of the humerus caused a tingling, “pins and needles” sensation in the same distribution. 

Cerebellar Function:  Intact.

Gait and Stance:  Not tested.


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 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.  Indicate the level of the neurologic lesion in this case and the structures involved by the pathologic process. 

5.  Where is the anatomical location of the pathologic process leading to this patient’s condition? 

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

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


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