Case History #197
Date of Consultation: 6-7-1989
HISTORY OF PRESENT ILLNESS:
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.
NEUROLOGICAL EXAMINATION:
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.
Questions
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?
Answers