2005 Exam I Case 05
Chief Complaint:
An 18 year-old, left-handed, male college student was brought into the local ER status post receiving a gun shot wound to his flank. A small entry hole was located on his right side posterior to the mid-axillary line at approximately the T6 level.
History of Chief Complaint
The patient had enjoyed good health until he and a friend went into the basement to see a supposedly unloaded pistol. The patient received his wound when his friend inadvertently pulled the trigger while turning to show the weapon.
Family History:
He has a girlfriend of 1 year, 2 healthy older brothers, and both parents are alive and healthy. He is currently living with his parents.
General Physical Examination:
The patient is a stable male presenting with a penetrating wound to the right flank. The projectile entered the flank approximately 2.5 cm posterior to the mid-axillary line, level with T6. No exit wound was found. CT of the abdomen and chest coursed the missile through the right upper lung lobe with penetrance of the spinal cord, no other organs appeared to be affected. The patient is awake and distressed. He is well nourished and hydrated. Vitals: HR: 120 RR: 20 BP: 100/60 Pulses diminished in both lower extremities.
Neurological Examination:
Mental Status: His fund of knowledge was intact, he was awake and oriented to person, place, and time and in obvious distress.
Cranial Nerves: Range of eye movement was full. Corneal, pupillary, and gag reflexes were intact. Facial movements were full and symmetric, hearing was intact bilaterally to finger-rub, and the tongue and uvula were midline.
Motor System: Full strength and range of motion was found in his upper extremities bilaterally. Strength was 0/5 throughout the right lower extremity with very mild weakness noted throughout the left lower extremity. Deep tendon reflexes were 2/4 for both upper extremities, 0/4 in the right lower extremity and ¼ in the left lower extremity.
Sensory Exam: Sensation to pain and temperature was present on the right and absent on the left below T7. Vibratory, position, and discriminatory sense were absent on the right T6 and below and normal on the left with the exception of a loss at the foot and ankle. Upper extremity senses were intact bilaterally.
Follow-up:
Three weeks later, strength deficits of the left lower extremity had resolved with deep tendon reflexes being 2/4. Right lower extremity strength remained 0/5 however deep tendon reflexes were 4/4 and a Babinski sign was elicited. Marked clonus could be elicited at the ankle on the right. Vibratory and position sense had returned in the left foot and ankle but were blunted throughout the right lower extremity.
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01 On initial presentation, the motor deficit expressed in the patient’s right lower extremity is best described as:
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02 On follow-up examination, the motor deficit expressed in the patient’s right lower extremity is best described as:
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03 Typically, ankle clonus is demonstrated by:
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04 The absence of pain sensation on the left and the loss of vibration sense on the right is best termed:
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05 The loss of pain sensation from the left side is most likely due to a lesion of the:
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06 The transient loss of vibratory and position sense from the left foot and ankle is most likely due to a lesion of the:
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07 In this patient, the most likely place to find chromatolytic neurons would be in the:
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08 In this patient the most likely location to find degenerating axons would be in the:
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09 The distribution of the major neurologic injury in this patient is best described as:
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