Case 25 - History - Neurology Clerkship

Case 25

Author: B. Jane Distad, MD

This is a 37 year-old male who complains of pain and right leg weakness. It began two months ago. He was bending down to lift a chair and developed acute pain in the right back and buttocks. Painful sensations radiated into his lateral calf and top of the foot. It was associated with numbness that started in his right big toe, 2nd and 3rd toes. The patient reports the pain is worse with sitting, but standing and walking are also bad. He denies bowel or bladder problems, left leg symptoms, and the arms are fine.

PMH: Intermittent low back pain.

Medications: Oxycodone.

Allergies: PCN causes rash.

Family History: Noncontributory

Social History: He is currently unemployed. He has been a one pack a day smoker
for 19 years. Drinks occasionally.

Physical:
BP 112/60 HR 72 T 36.7°C Wt __
General: Thin. No acute distress.
Mental Status: Alert and oriented x 3. Speech fluent without dysarthria.
HEENT: Head was normocephalic and atraumatic. Neck was supple, with full range of motion.
CN: 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. The palate elevated symmetrically. Full sternocleidomastoid strength. The tongue was midline and strong.
Motor (Power/Tone/Bulk): 5/5 left lower extremity. Right: 5/5 hip flexion, 5/5 knee flexion and extension, 4-/5 dorsiflexion, 5/5 plantar flexion, and 4-/5 EHL. No atrophy. Right straight leg raise caused pain down the lateral leg.
Sensory: Sensation was intact to light touch, pin prick and proprioception bilaterally in the upper and lower extremities, except in the dorsum of the right foot and great toe.
Reflexes: 2/4 bilateral biceps, brachioradialis, triceps, patellar and Achilles.
Coordination: Finger-to-nose and rapid alternating movements were intact bilaterally.
Gait: Antalgic, without ataxia. Patient unwilling to try toe or heel walking due to pain.
Abnormal Movements: None.
Other Organs: Noncontributory.