2004 Exam I Case 01
Chief Complaint:
A 31-year-old, right-handed female presents to the physician’s office today reporting that 2 days ago, she accidentally touched the burner on her stovetop with the fingers of her right hand and noticed that she did not feel pain.
History of Chief Complaint:
She had been diagnosed in her early 20’s with a congenital malformation of the cerebellum characterized by herniation of the cerebellar tonsils through the foramen magnum. She was informed at the time of diagnosis, that there were possible complications related to this abnormality and she comes in today concerned that her new symptoms may be related to her earlier diagnosis. Upon further questioning, the patient reveals that within the past 3½ yrs., she has noticed increasing frequency of moderate to severe suboccipital headaches. She describes a deep, constant, dull ache present in the cervical region, which she says she noticed about 10 months ago, along with mild weakness in both her upper extremities. Around 3 months ago, she began to notice a mild weakness in her lower extremities bilaterally. She has noticed in the past month feeling constantly short of breath.
Family History:
She is married and has 2 young children. Both her mother and father are in good health.
General Physical Examination:
Vital Signs: BP: 120/80 Pulse: 80 Temp: 98.6◦F Resp: 20 Height: 5’2” Weight: 119lbs. Patient is a well-groomed, pleasant female who appears her stated age. She is cooperative and appears concerned about her current situation. Head is normocephalic and without evidence of trauma. Neck is supple and without evidence of trauma, bruit, and lymphadeopathy. S1, S2 present. No gallops or murmurs. Respirations are rapid and short in duration and there is contraction of the sternocleidomastoid with each inspiration. There is decreased diaphragmatic excursion bilaterally. Chest is clear to auscultation without crackles, ronchi, and wheezing. Abdomen soft to palpation and without tenderness. No palpable masses or abdominal bruit. There is notable atrophy in the musculature of both upper extremities.
Neurological Examination:
Mental Status: Patient is alert and oriented to person, place and time with appropriate memory and knowledge base. Speech is meaningful. She can follow multistep commands.
Cranial Nerves: Extraoccular muscles intact bilaterally. Pupils reactive to light and accommodation. Facial movements are full. Corneal, jaw jerk, and gag reflexes intact. Hearing is intact to finger rub. Tongue protrudes midline and is without fasiculations.
Motor System: Strength in the upper extremity is 4/5 at the shoulder, 3/5 at the biceps, triceps and brachioradialis bilaterally. Grip strength 4/5 in the right hand and 3/5 in the left hand. Both upper extremities have decreased deep tendon reflexes at the elbow and wrist. There is significant muscle atrophy in both upper extremities. Strength in the lower limb is 3/5 at the hip and ankle and 4/5 at the knee bilaterally. DTR’s are elevated in both lower extremities and a Babinski response could be elicited bilaterally.
Sensory Exam: There is a dense loss of pinprick sensation present within the distribution of the C5, C6, C7, and C8 dermatomes bilaterally. Two-point discrimination, vibration and proprioception were intact in all areas of the body including the upper limbs.
Follow-up:
At examination one month later, the patient states that she has increasing shortness of breath. Motor testing demonstrates no change in upper extremity strength with the exception of grip strength in the right hand, which is now 3/5. Deep tendon reflexes in the upper extremity are still depressed and evidence of muscle atrophy is still present. There is no change in the motor function of the lower limb. Deep tendon reflexes remain elevated and a Babinski response could be elicited bilaterally in the lower limb. Sensory examination reveals a loss of response to pinprick expressed within dermatomes C4 through T1 bilaterally
INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.
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01 The motor defect expressed in the patient’s upper extremity is best termed:
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02 The motor defect expressed in the patient’s upper extremity is most likely due to damage to the:
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03 The motor defect expressed in the patient’s lower extremity is best termed:
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04 The motor defect expressed in the patient’s lower extremity is most likely due to damage to the:
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05 The sensory loss expressed in this patient is best termed:
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06 The downward expanding sensory loss expressed in this patient is most likely due to damage to the:
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07 The shortness of breath expressed in this patient is best termed:
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08 The shortness of breath experienced in this patient is most likely due to damage to the:
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09 In this patient, the most likely location to find chromatolytic neurons would be the:
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10 In this patient, the most likely location to find degenerating axons would be in the:
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11 The best description of the temporal sequence for the onset of her neurologic presentation is:
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12 The best description of the distribution of the neurologic lesion in this patient is:
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13 The best description of the neurologic pathology that has occurred in this patient would be:
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