Case History #53

Date of Consultation: 6-20-1980

HISTORY OF PRESENT ILLNESS:

This 4-year-old white male was referred for neurologic consultation and management of right upper limb weakness.  Twelve weeks prior to consultation, the child complained of slight headache and fatigue at the end of the day.  His temperature was 38 degrees C. (100.4 degrees F.), and he was restless through the night.  The next morning he was drowsy and, when aroused, could not move his right upper limb.  At that time, his temperature was normal, and his systemic symptoms had resolved.  He was evaluated and treated at another institution and ultimately underwent inpatient rehabilitation.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Intact.

Motor System:  Records from his hospital admission indicated that, initially, there were no areas of focal muscular atrophy.  However, at the time of consultation, the right upper limb showed marked wasting throughout.  Fasciculations in the muscles of the right upper limb were reportedly present throughout the early weeks of the illness, but no fasciculations were visible at this time.  Muscle tone was greatly reduced in the right upper limb but was normal in the other limbs.  Muscle power was normal in the left upper limb and both lower limbs.  Voluntary movement of the right upper limb was absent. 

Reflexes:  Deep tendon reflexes were absent in the right upper limb but were normal in the left upper limb and both lower limbs.  Plantar reflexes were flexor bilaterally.

Sensory System:  Intact.

Cerebellar Function:  Intact.

Gait and Stance:  Intact.