Neurology Clerkships
Case 27  
Author: B. Jane Distad, MD
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This is a 25-year-old male who presents with headaches. They have been present for several years. The whole head is involved and there is associated stomach pain.

He has had multiple tumors resected from the bilateral lower extremities and ultimately underwent an amputation below the right knee for bone-associated tumors. He has had a prior right temporal lobe and left cerebellar partial resections for tumor.

His last MRI was approximately five years prior. The patient and his parents are not aware of any new symptoms. His vision is unchanged and he has undergone an eye examination recently. He has had no change in his voice, swallowing, balance, sensation or strength. The only concern his mother had is that sometimes his eyes appear "glazed over." This occurs more often when he is playing video games, but can occur other times. She is often able to get his attention during this time if she is persistent.

1. Multiple surgeries, as above.

1. Tylenol, as needed.


Family History: Positive for tumors in the patient's two brothers, including a malignant tumor in the region of the pharynx. His mother has skin tumors, as does a maternal uncle.

Social History: The patient works as a dishwasher at Lakeside School. He lives with his parents. He reports he was recently in the Special Olympics and was awarded three medals.

BP 112/60   HR 72    T 37.0°C
General: The patient has a mild speech impediment with difficulty pronouncing "r." He has a very high-pitched voice, especially when he appears more excited about something.
Mental Status: Alert and O x 3
HEENT: II: Visual acuity 20/25 OD, 20/20 OS. Left optic disk is sharp and flat. There is subtle irregular border over the superior nasal aspect of the right optic nerve and the border is sharp. III, IV, VI: The pupils are equal, round and reactive to light and accommodation. Extraocular movements were full, without nystagmus. V: Normal facial sensation. 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 and tone throughout. No contractures were noted. Normal strength in the bilateral upper extremities and left lower extremity. Normal right proximal leg strength.
Sensory: Normal to light touch, cold and vibratory sense.
Reflexes: 1/4 in the arms. 3/4 at the knees. 2/4 left knee. 0/4 left ankle. Downgoing toe.
Coordination: Finger-to-nose testing, fine finger movements and rapid alternating movements of the hands were minimally slowed on the right.
Gait: Limp on right leg.
Abnormal Movements: None.
Other Organs: There is amputation approximately 12 cm below the right knee and thinning of the musculature in that region. There are scars over the posterior right flank in the region of prior surgeries. There is a 1.5 cm lesion, approximately 1 cm in height, on the left lateral foot. There are lightly pigmented spots in multiple areas and extensive freckling in the axillary regions. Multiple cutaneous and subcutaneous soft nodules. There is also an area of scar from prior surgery vertically in the mid cervical region.


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