Case History #43

Date of Admission: 12-1-1978

HISTORY OF PRESENT ILLNESS:

This 45-year-old right-handed white female was admitted to the hospital for left-sided weakness and focal seizures.  Around 11-1-78, the patient noted the gradual onset of left-sided weakness, numbness, and tingling, especially involving the left hand.  These symptoms were slowly progressive over the subsequent month.  On 11-26-78, the patient experienced a left simple partial (focal) seizure with a “Jacksonian march,” which began in the left hand and eventually involved the entire left side of the body.  She was placed on Dilantin by an emergency room physician.  On 11-29-78, the patient had 2 further episodes of left focal seizures, and the Dilantin dosage was increased.  She was admitted to the hospital for further evaluation. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Intact.

Motor System:  There were no areas of focal muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal on the right side of the body.  On the left side, there was a mild (4 to 4+/5) weakness in the upper and lower extremities. 

Reflexes:  Deep tendon reflexes were slightly brisker on the left side than the right.  Plantar reflexes were flexor on the right and equivocal on the left.

Sensory System:  Light touch, vibration, and pinprick were intact and symmetric bilaterally.  Joint position sense, stereognosis, graphesthesia, and two-point discrimination were entirely normal on the right side and were diminished or absent on the left side.

Cerebellar Function:  Intact.

Gait and Stance:  Intact.

Questions:

1.  What is the localizing significance of this patient’s sensory examination?  What types of sensory modalities were impaired?

2.  Damage to what area of the brain produces an impairment of the sensory modalities involved in this case?

3.  What other structures are involved in this case?  Where would you localize the lesion in this case?  Indicate the side of the brain involved.

4.  In general, what type of pathologic process was involved in this case?

5.  What diagnostic procedure(s) would you undertake at this point?