Neurology Clerkships
Case 8  
Author: B. Jane Distad, MD
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This is a right-hand-dominant, 15-year-old female, who reports arm weakness when playing her flute and styling her hair. Onset was 2 months ago and it is progressing. More recently she has difficulty running and swallowing. Twice she has had horizontal diplopia for 15 minutes. Resting helps some. She denies numbness, bowel/bladder change or cognitive difficulties.

PMH: Reactive airways disease.

Medications: None.

Allergies: NKDA

Family History: Negative.

Social History: Home schooling, her mother has custody, parents divorced. No alcohol, tobacco or drug use.

ROS: Rhinorrhea, neck and back pain, weight loss

BP 88/40   HR 72
General: Thin. Mild distress.
Mental Status: Alert and oriented x 3. Speech without dysarthria, but with nasal quality.
HEENT: Her head is normocephalic and atraumatic. Neck supple, with full range of motion. Weak neck extension and flexion. Pupils were equal, round and reactive to light. Extraocular movements were intact without nystagmus. Facial sensation was intact in the V1 through V3 distributions bilaterally. Normal jaw strength. Moderate facial weakness with eye closure and holding air in cheeks. The palate elevated symmetrically. The tongue was midline without fasciculations. Sustained upgaze was equivocal for ptosis after 90 seconds.
Motor (Power/Tone/Bulk): Strength bilaterally: 4/5 biceps, deltoids, triceps; 5/5 wrist flexors, wrist extensors, interossei; 4/5 hip flexors and hip extensors; 5/5 knee extensors and knee flexors; 3/5 ankle dorsiflexors; and 4+/5 ankle plantar flexors. Unable to stand from seated position without assistance.
Sensory: Sensation was intact to light touch, pin prick and proprioception bilaterally in the upper and lower extremities. Romberg was absent.
Reflexes: 2+ at the biceps, triceps, brachioradialis, patella and Achilles. Toes were downgoing to plantar stimulation bilaterally.
Coordination: Finger-to-nose poor secondary to weakness, and rapid alternating movements were intact bilaterally.
Gait: Labored with bilateral foot drop.
Abnormal Movements: None.
Other Organs: Noncontributory.

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