Localization of Neurologic Disease
Look for alteration in consciousness, deficits of the face/eyes.
- temporal - receptive.
- Posterior cerebral distribution
- Visual field loss +/- macular sparing.
- Alexia without agaphia (left + corpus callosum).
- Myopathy: sensory usually not involved, although may have pain. Weakness is proximal > distal.
- Myositis - took for associated findings such as rash, alopecia, joint pain/swelling.
- Hereditary myopathies - exercise intolerance, progressive weakness.
NEUROLOGICAL LOCALIZATION - CASES
26 year-old female graduate student was conducting a philosophy seminar when she suddenly started stuttering and then became incoherent. She seemed confused, and her mouth was twisted. One arm hung limply and she walked unsteadily. She had a past history of rheumatic heart disease and took no meds except for birth control pills.
68 year-old white female presents with CC of inability to walk. Upon further questioning you find that this has progressed over a month or two and is not associated with back pain. On exam she is slightly inattentive and sometimes inappropriate. Language is intact. She has no CN deficits, and good strength of the UE's. Her legs are diffusely weak, 3 to 4 over 5, proximally and distally. Sensory exam reveals questionable mild loss of LT/PP distally of LE's, with no demarcated level. Reflexes are brisk in the legs and she has bilateral Babinski's.
55 year-old black female with a history of DM and Htn states that while drinking her morning coffee she suddenly experienced "heaviness" of the right arm. She fumbled with the cup until she spilled the coffee, and when the symptoms did not resolve within a half hour she reported to the ER. Examination reveals an alert woman with normal mental status, decreased LT, PP, Vibration over the night arm and leg. Strength is objectively normal.
Your friend, who is a body builder, complains of sudden back pain and the inability to walk. Your exam reveals bilateral leg weakness, with absent ankle reflexes, decreased tone in legs. He feels paresthesias running down the back of both legs, and didn't notice you sticking him with a pin until you got to the mid-thigh. Pressure on the lumbar spine causes pain, and he has paralumbar spasm.
A 35 year-old black male is seen in clinic with 3 month history of weakness and muscle cramps, first felt in the left arm but progressing to both legs. His voice is not as loud as it used to be, and is a little hoarse. Sometimes food gets "stuck" on one side of his mouth and he has to move it with his finger. He has no sensory loss. Reflexes are brisk, including a jaw jerk. The toes are equivocal. Fasciculations are present in the tongue at rest, and all four proximal extremities. One year later he has difficulty swallowing, is short of breath and appears emaciated.
A 62 year-old woman complains of pain and numbness of the hand. She has been dropping objects from the hand, but the discomfort is worse at night.
A 16 year-old woman is referred to you by her psychiatrist. For the last year she has complained of weakness which came on after the death of her father. The weakness seems to come and go depending on her family situation or her depression. She also complains of a vague tightness of her throat ("globus hystericus"), leg aching and frequent headaches. Sometimes she is fine, and other times she just lays on the couch, or will suddenly fall walking off a curb. She admits she doesn't know anymore why she can't pull herself out of this.
A 30 year-old white female has difficulty climbing stairs. She cannot lift objects but has no problems writing or buttoning her shirt. Her gait is waddling. She has been followed for 8 months in the rheumatology clinic for "arthritis". A visit to the walk-in clinic prompted her appointment with neurology. Her joints have good range of motion and are nonfluctuant. Her muscles are tender to palpation.
A 28 year-old white female complains of headaches for 1 year, recently daily. They are often throbbing, usually bitemporal and do not usually cause too much nausea, although she has vomited once or twice. She also says her vision has changed, but she went to get her glasses checked and they told her they were fine. Other pertinent history is obtained that she had a child 9 months ago, and gained 80 pounds during pregnancy. She has lost 30. On physical exam, she is obese. Vital signs are normal. Funduscopic exam shows bilateral disc margin blurring with a flame hemorrhage in the right. Pupils are equally reactive. Visual fields are full on finger confrontation. There is a question of mild lateral rectus weakness on the right. The rest of the cranial nerves are normal as is her strength, sensation, and reflexes. There is no Babinski. Coordination and gait are intact. CT of the head is normal. EEG is normal. CSF is normal except for an opening pressure of 410 mm H20.
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