Case History #64
Date of Admission: 10-7-1988
HISTORY OF PRESENT ILLNESS:
This 17-year-old right-handed white female high school student was
admitted to the hospital for evaluation of left-sided weakness.
Five days prior to admission, the patient developed a cold with a runny
nose and nasal congestion. Three days prior to admission, she
noted that she was tripping over her left foot when she attempted to
walk. The next day, she felt that the entire left side of her
body was numb, and her father told her that the left side of her mouth
did not seem to be working as well as the right side. At that
point, the symptoms seemed to stabilize and mainly affected her walking
and coordination of her left upper limb. She was admitted to the
hospital for further observation and investigation.
NEUROLOGICAL EXAMINATION:
Mental Status Exam: Intact.
Cranial Nerves: Cranial nerve
examination was normal except for the following. There was
weakness of the lower facial muscles on the left side, but the patient
was able to close her eyelids tightly and wrinkle her forehead
symmetrically on both sides.
Motor System: There were no
areas of focal muscular atrophy or fasciculations. Muscle tone
was normal in all 4 limbs. Muscle power was normal on the right
side. On the left side, there was a moderate degree of weakness
(4/5) involving all muscle groups in the upper and lower limbs, with
the upper limb being slightly worse than the lower limb.
Reflexes:
Deep tendon reflexes were normal (2/4) and symmetric in the upper
limbs. In the lower limbs, the knee jerks were 2/4 on the right
and 3/4 on the left, and the ankle jerks were 1/4 on the right and 2/4
on the left. Plantar reflexes were flexor on the right and
extensor on the left.
Sensory System: Sensory
examination was entirely normal in all 4 limbs.
Cerebellar Function: Intact on
the right side. On the left side, cerebellar tests were
essentially intact, although somewhat difficult to interpret because of
the patient’s weakness.
Gait and Stance: Regular gait
was performed with circumduction and a mild degree of spasticity
involving the left lower limb. Tandem gait was difficult due to
the left lower limb weakness. The Romberg test was negative.
Questions
1. Is the weakness on
the left side of the face of the upper motor neuron or lower motor
neuron type?
2. Is the weakness on the left side of the body of the upper
motor neuron or lower motor neuron type?
3. What specific structure is involved by the pathologic process
to produce the patient’s left facial
weakness?
4. What specific structure is involved by the pathologic process
to produce the patient’s left hemiparesis?
5. Is it possible to specifically localize the lesion in this
case? If so, where is the lesion localized, including the
side. If not, indicate the possible sites of localization of the
lesion, the side involved, and the specific structure(s) involved by
the pathologic process.
6. This patient’s clinical findings represent a classic
neurological syndrome. What is the name of that syndrome, and
what is its usual cause?
7. In general, what type of pathologic process is involved in
this case?
8. What diagnostic procedure(s) would you undertake at this point?
