Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #198

Date of Consultation: 7-3-1990


This 32-year-old right-handed white male graduate student was referred for neurological consultation because of right shoulder pain and weakness.  The patient recalled being bitten by a tic on 6-9-1990 while visiting friends in Massachusetts.  A few days later, he had a mild fever, myalgias, and a sore throat.  About one week later, he awoke with pain involving the right shoulder, scapular region, and posterolateral upper arm.  After about three days of these symptoms, he went to his primary care doctor, who noted a right posterior triangle lymph node.  Tests for mononucleosis were negative, and his symptoms resolved approximately 24 hours later.

He went on a backpacking trip for the next two weeks and did not notice any symptoms except that his right shoulder felt “heavy”.  Upon returning home, he noted that his right shoulder muscles felt weak, and his internist referred him for neurological evaluation.  He specifically denied any rash, joint or musculoskeletal pain except for his initial right shoulder pain, or any other systemic or infectious signs or symptoms other than the initial symptoms mentioned above.


Mental Status Exam:  Intact. 
Cranial Nerves:  Intact, including the absence of anisocoria, ptosis, or alteration of sweating on the face.

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 in all four limbs, except for the right shoulder girdle muscles.  The patient had definite winging of the right scapula, when pressing against the wall with his outstretched hands (see slides #1 and 2).  He also was only able to abduct his right arm at the shoulder joint to approximately 135 degrees, as opposed to full 180 degrees abduction on the left.  There was no weakness of other shoulder girdle muscles, including the deltoid and supraspinatus muscles.

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

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

Cerebellar Function:  Intact.

Gait and Stance:  Intact.


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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