Neurology Clerkships
Case 26  
Author: B. Jane Distad, MD
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This is a 62-year-old male with 6 months of right arm symptoms. While lifting his bags into the overhead compartment of an airplane, he experienced right neck and shoulder pain. Shortly thereafter, he had weakness in the right upper extremity which has persisted. He also has tingling of the right forearm and thumb which has improved. He underwent plain films of the neck, and he was told he had arthritis.

ROS negative for symptoms in the left arm, legs, bladder, speech, swallow or vision.

1. Diabetes since 1995.
2. Depression.
3. Prostate cancer.
4. Dyslipidemia.

1. Glucophage
2. Avandia
3. Neurontin
4. Zestril
5. Paxil
6. Aspirin
7. Lipitor

Allergies: Sulfa causing a rash.

Family History: Negative for neurological disorders.

Social History: The patient is a hotel manager. He is in the "hospitality industry." He smokes half-a-pack per day and drinks about fifteen ounces per week.

BP 148/72    HR 108     T 37.60C
General: Well appearing.
Mental Status: Normal.
HEENT: II: Visual acuity was 20/20 bilaterally. Visual fields were full to confrontation. Funduscopic examination revealed flat discs with venous pulsations seen bilaterally. III, IV, VI: The pupils are equal, round and reactive to light and accommodation. Extraocular movements were full, without nystagmus. V: There was normal motor and sensory function. VII: There was a symmetrical nasolabial fold without volitional weakness. VIII: Hearing was intact to finger rubbing bilaterally. IX, X: Palate elevation is symmetrical in the midline. XI: Sternocleidomastoid was strong bilaterally. XII: Tongue with normal bulk, strength and movement.
Motor (Power/Tone/Bulk): Normal bulk, tone and strength throughout except the following. Muscle strength 3/5 in the right deltoid, biceps, brachioradialis. Supraspinatus and infraspinatus 4/5. Atrophy present in the same muscles.
Sensory: Vibratory sense was diminished to ten seconds bilaterally at the toes. Joint position sense was intact at the toes. Romberg was minimally unsteady. Pinprick and light touch were abnormal to the distal few centimeters of either foot with some abnormal sensation at the ball of the feet bilaterally. Pinprick and light touch reduced in the right lateral forearm and thumb.
Reflexes: Biceps 0/4 on the right, 2/4 on the left; triceps 2/4; brachioradialis 0/4 on the right, 2/4 on the left; knee jerk 2/4; ankle jerk 1/4. Both toes downgoing.
Coordination: Finger-to-nose testing could not be done on the right. HKS normal bilaterally.
Gait: Tandem was unsteady. Heel walking and toe walking were normal.
Abnormal Movements: None.
Other Organs: Noncontributory.

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