Case History #5
Date of Consultation: 12-3-1987
HISTORY OF PRESENT ILLNESS:
This 39-year-old right-handed white male electrician was referred for neurological consultation because of right hand symptoms. The patient indicated that in September 1987 he awoke one morning and noticed numbness and tingling in the lateral 3 or 3½ digits of the right hand. Initially, these symptoms were intermittent and were most prominent in the thumb and index finger. As time passed, they became more persistent and, at the time of consultation, were constantly present. The symptoms consisted of numbness and tingling involving the lateral 3 or 3½ digits of the right hand; although, when the symptoms intensified, they seemed to radiate up along the lateral aspect of the right forearm as well. The patient did not notice any weakness in the right hand or the right upper limb. At times, these symptoms began in the middle of the night and awakened him from sleep. At those times, he often felt as if the entire right upper limb was symptomatic. The only other factor that intensified the symptoms was unusual head or neck positions. The patient also noticed pain in the neck and a degree of neck stiffness; although he did not complain of sharp, shooting pains radiating from the neck down the right upper limb.
NEUROLOGICAL EXAMINATION:
Mental Status Exam: Intact.
Cranial Nerves: Intact.
Motor System: There were no areas of focal muscular atrophy or fasciculations. Muscle tone was normal in all 4 limbs. Muscle power was normal in all 4 limbs, except for a very mild weakness (4+/5) of abduction of the right thumb and flexion of the right thumb at the metacarpophalangeal joint.
Reflexes: Deep tendon reflexes were equal and symmetric in all 4 limbs. Plantar reflexes were flexor bilaterally. There was a Tinel sign at the right wrist, but the Phalen test was negative.
Sensory System: Sensory examination was normal in all 4 limbs except for the following. There was a subtle decreased appreciation of pinprick and light touch on the anterior or palmar surface of the lateral 3½ digits of the right hand.
Cerebellar Function: Intact.
Gait and Stance: Intact.
Questions
1. Is there evidence of spinal cord involvement in this case and, if so, at what level(s)?
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? If so, indicate the specific structure(s) involved by the pathologic process.
4. Where is the anatomical location of the pathologic process leading to this patient’s condition?
5. In general, what type of pathological process do you think is involved in this case?
6. What diagnostic procedure(s) would you undertake at this point?