Case History #2
Date of Consultation: 3-12-1987
HISTORY OF PRESENT ILLNESS:
This 45-year-old white female pawnshop clerk was referred for neurological consultation because of a 6 week history of neck pain. The patient stated that this pain began intermittently but gradually became more severe and persistent. The pain was located in the lower part of the posterior aspect of the neck and was increased by flexing the neck. She denied any radiation of the pain into either the left or the right upper limb and also denied any numbness, tingling, or weakness in the upper limbs.
About one week after the onset of her neck pain, the patient noted that her left eyelid was drooping. A lack of sweating on the left side of the face and head was also observed at this time and continues to the present.
In the spring of 1984, the patient noted a lump in her right breast, and biopsy subsequently proved this to be malignant. In July 1984, she underwent a modified right radical mastectomy for carcinoma of the breast. There were lymph node metastases at that time. She underwent chemotherapy, but, in August 1986, she was found to have a recurrence of tumor in the right chest wall and also in a left axillary lymph node. Her chemotherapy was changed, and she did well until February 1987, when she began developing the pain in her low neck.
NEUROLOGICAL EXAMINATION:
Mental Status Exam: Intact.
Cranial Nerves: All cranial nerve functions were normal except for the following. The pupils were asymmetric with the left pupil measuring 1.5 mm and the right measuring 2.5 mm. Both were reactive to light. There was a 2 mm ptosis of the left eyelid. There was also an absence of sweating on the entire left side of the face and the head. Extraocular movements were entirely intact.
Motor System: Intact.
Reflexes: Deep tendon reflexes were brisk but symmetric. Plantar reflexes were flexor bilaterally.
Sensory System: Intact.
Cerebellar Function: Intact.
Gait and Stance: Intact.
Head and Neck Exam: Neck range of motion was restricted in all directions but especially so on forward flexion. There was severe posterior neck muscle spasm, and neck movements elicited considerable pain.
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 brachial plexus or peripheral nerve involvement in this case, and, if so, how would you differentiate between the two?
4. Is there evidence of autonomic nervous system involvement in this case? If so, what signs and symptoms support this conclusion?
5. What is the localizing significance of the left-sided ptosis, miosis, and absence of sweating (anhidrosis), and what specific structures are involved by the pathologic process to produce these signs?
6. This combination of signs and symptoms constitutes a classic neurologic syndrome. What is the name of that syndrome?
7. In general, what type of pathologic process do you think is involved in this case?
8. What diagnostic procedure(s) would you undertake at this point?