Case History #33
Date of Consultation: 3-10-1980
HISTORY OF PRESENT ILLNESS:
This 84-year-old right-handed black female was admitted to the hospital for evaluation of abnormal movements of the left upper extremity. The patient’s neurologic history was significant for multiple cerebral infarcts in the past, leaving her with significant disability. Beginning 4 years earlier, the patient suffered a series of left hemisphere infarcts which left her severely aphasic and with a right hemiplegia. The patient’s daughter indicated that she had never experienced involvement of the left side of the body with any of these infarcts.
The patient’s daughter indicated that, approximately 2 to 3 weeks prior to admission, the patient suffered the acute onset of left-sided weakness that was followed immediately by the onset of rather dramatic involuntary movements of the left upper and lower extremities. Her internist prescribed Dilantin for “seizures,” but this did not help control the movements. The movements continued to worsen, and the patient was admitted to the hospital for further evaluation and observation. Throughout the course of her illness, the left upper extremity was more involved than the left lower extremity. The movements increased with attention, anxiety, and agitation and decreased during sleep.
NEUROLOGICAL EXAMINATION:
Mental Status Exam: The patient was awake and alert. She exhibited a global aphasia in that she was not able to produce any speech whatsoever and gave no evidence of comprehension of speech. Therefore, no further mental status testing was possible.
Cranial Nerves: Cranial nerve examination was normal within the limits of patient cooperation.
Motor System: There were no areas of focal muscular atrophy. There were no fasciculations. Muscle tone was increased in the right upper and lower extremities, and there were contractures of those limbs due to her prior strokes. Muscle tone could not be properly assessed on the left side due to the patient’s involuntary movements. Muscle power was extremely limited on the right side due to both weakness and contractures. On the left side, muscle power appeared to be grossly within normal limits. Involuntary movements were noted on the left side with the upper extremity being more involved than the lower extremity. These movements ranged from rapid, irregular jerking and writhing movements of the limbs, when the patient was quiet and resting, to coarse, wide excursion, irregular flinging movements of the limbs when she was mildly stimulated. These movements involved the proximal parts of the limbs more than the distal parts.
Reflexes: Deep tendon reflexes were brisk bilaterally but more so on the right than the left. Plantar reflexes were extensor on the right and probably flexor on the left (difficult to interpret due to constant movement).
Sensory System: Sensory examination appeared to be grossly normal and symmetric in all 4 limbs, although patient cooperation was limited due to her language dysfunction.
Cerebellar Function: Cerebellar tests could not be performed on the right side due to contractures and weakness. Observation of movements failed to reveal any cerebellar abnormalities on the left side.
Gait and Stance: Not tested.Questions
1. Is there evidence of pyramidal system (i.e., upper motor neuron or corticospinal tract) involvement in this case. If so, what is the level or location of that involvement? What side of the central nervous system is involved? Is this involvement part of the patient’s acute neurologic problem or part of her prior neurologic events?
2. How would you classify this patient’s involuntary left-sided movements? Are these movements part of her acute neurologic problem or part of her past neurologic events?
3. Indicate the specific structure involved by the pathologic process, including the side of involvement.
4. In general, what type of pathologic process do you think is involved with this patient’s acute neurologic problem?
5. What diagnostic procedure(s) would you undertake at this point?