Case History #200
Date of Consultation: 6-5-1986
HISTORY
OF PRESENT ILLNESS:
This 52-year-old
right-handed Asian female University Registrar was referred for
neurologic evaluation because of right lower limb symptoms.
Approximately 1.5 to 2 years prior to consultation, the patient noted
the gradual onset of a numb, thick feeling in the second, third, and
fourth toes of the right foot. Over a period of several
months, she noted this sensation of numbness and thickness moving up
the right lower limb into the anterior, posterior, and lateral aspects
of the leg. The sensation continued to ascend to eventually
involve the lateral aspect of the thigh, buttock, and recently seemed
to involve the posterior lumbar area up to about the mid-thoracic
region as well. Along with this heavy, thick feeling, the
patient noted some difficulty appreciating painful stimuli in the right
lower limb and right foot and on occasion had difficulty knowing the
exact position of her right foot. At times, she noted that
she was dragging the right lower limb and felt that it was heavy and
somewhat weak. She noted that when walking she had a tendency
to circumduct the right foot and at times felt that the right lower
limb was stiff. The overall course of this problem was one of
a gradual progression over the past 1.5 to 2 years.
NEUROLOGICAL
EXAMINATION:
Mental
Status
Exam:
Intact.
Cranial
Nerves:
Cranial nerve examination was normal.
Motor
System:
There was no evidence of focal muscular atrophy or
fasciculations. Muscle tone was perhaps subtly increased in
the right lower limb when compared to the left but was symmetric in the
upper limbs. Muscle power was normal on the left side of the
body. On the right side, there was a mild (4+/5) weakness of
ankle dorsiflexion and a moderate weakness (4/5) of hip
flexion.
Reflexes:
Deep tendon reflexes were normal and symmetric (2/4) in the upper
limbs. In the lower limbs, the right knee jerk and ankle jerk
were slightly brisker than the left. Plantar reflexes were
flexor bilaterally.
Sensory
System:
Sensory examination was normal on the left side. On the right
side, there was an altered appreciation of pinprick throughout most of
the right lower limb and posterior trunk region. There
appeared to be an elevated sensory threshold, and, then once the
sensation was perceived, there was a disagreeable tingling associated
with it. Joint position sense was impaired in the right foot
when compared to the left.
Cerebellar
Function:
Intact.
Gait
and
Stance:
Regular gait was performed normally, although there was a slight
tendency to circumduct the right foot. Tandem gait was
normal, and the Romberg test was negative.
Questions:
1. Is there evidence
of peripheral nervous system (peripheral nerve, spinal nerve, or
dorsal/ventral root) involvement in this case, and, if so, what is the
level(s) of that involvement?
2. Are the patient’s right lower limb motor and reflex
examinations suggestive of an upper motor neuron or lower motor neuron
process?
3. Is there evidence of spinal cord involvement in this case and,
if so, at what level?
4. Could this patient’s signs and symptoms be localized to
any other place in the central nervous system? If so, what is the
precise localization of her neurologic lesion, including the side of
involvement? Indicate the specific structure(s) involved by this
lesion.
5. In general, what type of pathologic process do you think is
involved in this case, and what would be included in the differential
diagnosis?
6. What diagnostic procedure(s) would you undertake at this point?
Answers
