Case History #21

Date of Consultation: 3-21-1983

HISTORY OF PRESENT ILLNESS:

This 29-year-old right-handed white male truck driver was referred for neurological consultation because of headaches.  His headache problem had been present for approximately 20 years and appeared to be a common migraine problem unrelated to other neurologic symptoms.

However, upon questioning the patient, he gave a history of clumsiness of the left upper and lower limbs that had been present "as long as he could remember".  These symptoms were not particularly severe and did not appear to be progressive in any way.  He mentioned such factors as being somewhat less coordinated than most of the kids in school and having some difficulties with fine coordinated movements of the left hand and upper limb. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was entirely normal except for the following.  External ocular movements were full.  However, there was left beating nystagmus in left horizontal gaze. 

Motor System:  There were no areas of focal muscular atrophy.  There were no fasciculations.  Muscle tone and power were normal in all 4 limbs. 

Reflexes:  Deep tendon reflexes were equal and symmetric, and the plantar reflexes were flexor bilaterally.

Sensory System:  Intact.

Cerebellar Function:  All cerebellar tests were performed normally on the right side of the body.  On the left side, there was dysmetria and dyssynergia in both the upper and lower limbs.  There was a mild intention tremor in the left upper and lower limbs.  Rapid alternating movements were produced dysrhythmically in the left upper and lower limbs. 

Gait and Stance:  Regular gait was performed normally.  Tandem gait was somewhat difficult for the patient with a tendency to veer or lose his balance to the left side.  The Romberg test was negative.