Neurology Clerkships
Case 36  
Author: Joe Zunt, MD
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This is a 37 year-old male who developed acute onset weakness in his lower limbs. He had been previously healthy, with the exception of an upper respiratory illness two weeks prior to onset of the weakness. He states he awoke with an inability to move his lower limbs. He initially thought he had “slept on them wrong” but after one-half hour laying in bed, he noted no improvement and crawled out of his room and yelled for help. He states the legs feel “heavy” and he is unable to feel his legs when he pinches them. He also notes that he has not urinated or had a bowel movement since the previous night.

Review of systems is notable only for the URI two weeks ago-which consisted of fever, cough and congestion. He treated the symptoms with an over-the-counter medication and the symptoms resolved in 72 hours. He did note a pain in his upper back the night before the onset of weakness, but felt this was due to raking and lifting yard debris the previous day. He had been working as a day laborer but recalls no recent injury to his head or spine. He denies fever, rash or GI symptoms. He has had no similar symptoms in the past.

PMH: Broken femur as an adolescent

Medications: None

Allergies: NKDA

Family History: Father with diabetes. Mother with osteoarthritis.

Social History: Works as a day laborer. Lives with his parents. He uses occasional alcohol and marijuana.

BP 129/76   HR 70    T 37.5°C
General: muscular, no acute distress
Mental Status: alert and oriented x 3
HEENT: Normocephalic and atraumatic. Neck was supple, with full range of motion. The pupils were equal, round and reactive to light and there was no relative afferent pupillary defect. Extraocular movements were intact without nystagmus. Visual field testing was full to confrontation. Optic discs were sharp bilaterally with venous pulsations present. There was no facial weakness. Facial sensation was intact in the V1 through V3 distributions bilaterally. The palate elevated symmetrically. The tongue was midline and strong.
Motor (Power/Tone/Bulk)
: 5/5 bilaterally in the upper extremities. There was no movement in any muscles of the lower limbs Tone in the upper limbs was normal but was reduced in both lower limbs. No atrophy was present in the upper or lower limbs.
Sensory: Sensation was intact to light touch, pinprick and proprioception bilaterally in the upper extremities, but were all absent from the T4 level down. Romberg was not performed (patient unable to stand).
Reflexes: 2/4 at the bilateral biceps, triceps, brachioradialis, and absent (0/4) at the bilateral patella and Achilles. Toes were upgoing (extensor) to plantar stimulation bilaterally.
Coordination: Finger-to-nose and rapid alternating movements were intact in the upper limbs bilaterally.
Gait: Unable to walk.
Abnormal Movements: None
Other Organs: Noncontributory

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