HPI
A 14-year-old right handed male started out the summer playing shortstop for his Little League team and batting in the leadoff position. Six weeks later he was playing right field and batting eighth with a team in the lower level. He states that he cannot run as fast as he did during the beginning of the summer and that he cannot hit the ball as far or consistently. He notes that he uses his arms to lift off of the toilet and climbs stairs "one at a time" by bringing both legs up to the same step before he reaches for another stair. He denies pain, fever, rash, numbness, tingling, double vision or difficulty chewing or swallowing.
PMH
Unremarkable
Medications: None
PE
- General Exam: Unremarkable
NEURO
- MS: Normal
- CN: Normal
- MOTOR: A normal gait but he points his rear into the air and "climbs up his legs with his hands" in order to get up off the floor ("tripod maneuver"). He uses his arms to get up from a chair and collapses into the chair when sitting. Muscle testing reveals weakness of neck flexors (as compared with extensors), and weakness (right more than left) of the deltoids, supraspinatus, rhomboideus, iliopsoas, quadriceps, semitendinosis. Reflexes and tone are intact and toes are plantar flexor with plantar stimulation.
- Cerebellar Exam: No ataxia
Study Questions:
- What are the important features about his story?
- What are the important features about his examination?
- What neurological system(s) is (are) most likely affected?
- What pathophysiological processes could affect these neurological systems?
- What testing (anatomical, functional, or biochemical) could be ordered to test #3 and #4.
- What if the patient was 50 and reported a 15-pound weight loss in the last month and a cough?
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