Case 2
CASE 2: DESCRIPTION
35 year-old right handed woman with a history of cervical cancer presents with weakness and numbness of the legs which spread to torso and now fingertips. The left leg is more affected than the right. Symptoms have been worsening over the past 5 days. When she flexes her neck, she feels an electric shock-like pain down her spine. Today, she noticed double images when she looks to her right. Her symptoms are making it hard for her to work. Denies any prodromal illness, no trauma. History of vision loss and poor red color vision 2 years prior over several days in the right eye that resolved, but sometimes recurs with exercise.
SHx: Works as a teacher. Identifies as Mexican-American. Rare social alcohol use.
Vitals: afebrile, BP 110/70, HR 60, RR 12, O2 sat 100% on RA
General Exam: unremarkable
Neurologic Exam
Mental Status: alert, oriented x 3, intact language, command following
Cranial Nerves: Right optic disc pallor, VFFTC, PERRL but right afferent papillary defect (APD) on a swinging flashlight test (See videos 2A, 2B), no ptosis, EOM: intact on leftward gaze, on rightward gaze she reports horizontal diplopia, the left eye does not adduct and the right eye abducts but has nystagmus towards midline, face sensation intact, face symmetric and strong, no bulbar weakness
Motor: normal bulk, increased spastic tone in the lower extremities, 5/5 UE strength, LE with trace weakness of right leg, left weaker more markedly weak with 4/5 knee flexion, 4+/5 ankle dorsiflexion
Reflexes: 2+ UE, 3+ patellae with crossed adductors, +3 right ankle, +4 left ankle with sustained clonus, upgoing toes bilaterally
Sensory: Decreased sensation to pinprick from the nipple line down, decreased bilateral proprioception to ankles, Romberg absent
Coordination: normal
Gait: steady, spastic gait with scissoring