A 66-year-old photographer was ... - Anatomy Resources



Dental Student Case Set I, 2011 (modified from Waxman)

Case 1

A 66-year-old photographer was referred for evaluation of weakness, which started 9 months ago. Recently he began to have difficulty swallowing solid food and his speech had become thick. He could not tightly close his eyes and keep them closed when asked to resist the doctor’s effort to pry the lids open. He had poor elevation of the uvula. His scapula were winged, his tongue, hands and arms showed atrophy and fasciculation (look these up if you don’t know what these signs are). Cerebellar tests were normal. All sensory modalities were intact over his body and face.

Can all of this be explained as due to motor neuron involvement alone?

If so, where are the motor neurons that are diseased, damaged or degenerated?

Where do these motor neurons send their axons?

Do you think this is a stroke or cerebrovascular accident? Argue your point.

Case 2

A 24-year-old medical student noticed when he got up that he was unable to move the left side of his face. He had the flu a week before. His neurologic exam showed he could not wrinkle his forehead on the left side or tightly purse his lips when asked to whistle. He had trouble closing his left eye. He could clench his teeth and had normal facial sensation.

From this description what cranial nerve(s) is/are involved?

You are asked to localize the lesion and have no MRI! What might you test to narrow you choice of location of the lesion?

With just this information do you think if you touched the left cornea he would blink?

If so, on which sides?

What if you touched the right cornea?

Would he have tears on both sides?

Convincingly argue that this is a brain stem lesion or a peripheral nerve lesion. Peripheral means it has left the brain stem, not that it has exited the skull. Is there anything you could test that would further localize it?

Case 3

A 41-year-old woman complained of numbness and tingling in her right hand for more than a year. These sensations started gradually in the fingers but ultimately extended to the right hand and forearm. The patient was unable to do fine work such as sewing and she sometimes dropped objects because of weakness that had developed in that hand. Three weeks before she had burned two fingers of her right hand on the stove but had not felt the heat or experienced pain.

Neurologic exam showed wasting of the small muscles in the right hand and deep tendon reflexes in the right upper extremity were absent or diminished. Careful testing for vibration and proprioception in both arms and hands showed no abnormality on either side. However, pain and temperature were absent or diminished from these same areas on both sides. The sensory deficit when plotted on the skin surface took the shape of a cape over her shoulders and down the arms

Her problem is:

Peripheral nerves

Spinal cord

Medulla

Can you explain the woman’s problem with one continuous lesion? If so, where? Draw a picture and mark the neurons and tracts involved in this case as well as the approximate dermatomal level.

Does this patient show sensory dissociation? Explain.

How do you explain weakness in one hand and not the other?

Using the following diagram with the lesion area shaded state the SENSORY OR MOTOR deficit the patient would have.

(Images from Waxman).

LEFT RIGHT

This picture shows patients with lesions. It is also from Waxman.

You are standing behind the patient, so the patient’s right is on the right.

On the cross section of the cord draw the lesion and name the tracts or structures that are involved.

LEFT RIGHT LEFT RIGHT

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