What does this sound like to you?

[Shades McCool]

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A 31-year-old woman slips and falls at home, landing on her sacrum. Except for pain in the sacral area she has no other symptoms until the following day, when she complains to her husband that she is weak and numb on the right side.



On examination her mental status is normal, and she appears neither anxious nor depressed. Right-sided weakness of wrist extension, hip flexion, and ankle dorsiflexion is difficult to quantitate; the muscles seem to give way abruptly to any counterforce. All other muscles are of normal strength, including finger extensors, hip adductors, knee extensors, and toe dorsiflexors. There is decreased sensation over the entire right side including face, scalp, limbs, and trunk. Vibratory sensation is felt to the immediate left but not the immediate right of midline over the forehead, chin, and sternum. Proprioception is absent at all joints of the right arm and leg, yet she is able accurately to perform finger-to-nose testing bilaterally with her eyes closed. Her gait is not ataxic, but she walks holding her right leg stiffly with the knee fixed in extension and the ankle fixed in dorsiflexion. She reports that sounds are fainter in her right ear, and she sees colors less brightly with her right eye. When a 512-Hz tuning fork is held over her mid-forehead, the sound does not lateralize to either side, and her fundi and pupils are normal. Muscle tone and tendon and plantar reflexes are normal.

 

[02115]

A stroke although I have no idea where!!!

 

[exmike]

factitious disorder

 

[Shades McCool]

Yeah it isn't that fun of a case to try and figure out.

 

[lasek]

A Vibratory sensation is felt to the immediate left but not the immediate right of midline over the forehead, chin, and sternum.

For some reason I remember this being mentioned in class but am foggy on the details.
Such sharp demarcation of sensory loss exactly across the midline comes from either unilateral thalamic lesions, or faking. The distinction is the vibratory sensation on the forehead, which should be normal on both sides if its a true lesion because the bone transmits the vibration to the other normal side. If the patient is faking, they will say they dont feel the vibration on the effected side of the forehead.
I dont know how easy it is to fake the other stuff she has though. I sya its a toss up.

 

[Idiopathic]

Malingering/faking

She has matching right sided weakness and right sided numbness, with normal reflexes and it doesnt localize to any dermatome. No single neurological insult (save maybe MS?) could do this.

So, my zebra dx is massive MS episode but I really think its faking.

 

[JayZee]

SOMATIC DYSFUNCTION!

...the sacral dysfunction relating to the OA dysfunction...causing all the problems

😀 😀 😀 😀

 

[exmike]

wow, i was semi-joking with my factitious disorder diagnosis, but people seem to be leaning that way

 

[Shades McCool]

Malingering/faking

She has matching right sided weakness and right sided numbness, with normal reflexes and it doesnt localize to any dermatome. No single neurological insult (save maybe MS?) could do this.

So, my zebra dx is massive MS episode but I really think its faking.

I think you're very right. This is what does it for me "Vibratory sensation is felt to the immediate left but not the immediate right of midline over the forehead, chin, and sternum." You would feel it on both sides because the vibration would be felt on the "good" side if you put the tuning fork on the "bad" side like Lasek said.

 

[Idiopathic]

I think you're very right. This is what does it for me "Vibratory sensation is felt to the immediate left but not the immediate right of midline over the forehead, chin, and sternum." You would feel it on both sides because the vibration would be felt on the "good" side if you put the tuning fork on the "bad" side like Lasek said.

exactly. they think that by faking numbness exactly right of center they are playing the appropriate sign, when they would feel it on the left side even if it were placed just right of center.

 

[lasek]

exactly. they think that by faking numbness exactly right of center they are playing the appropriate sign, when they would feel it on the left side even if it were placed just right of center.

Not to mention she isnt anxious. I'd think someone who suddenly lost sensation over half their body would have some findings on the mental status exam or at least be anxious about it.

Out of curiosity, does anyone know how a unilateral thalamic lesion would present besides the sensory loss?

 

[exmike]

Not to mention she isnt anxious. I'd think someone who suddenly lost sensation over half their body would have some findings on the mental status exam or at least be anxious about it.

Out of curiosity, does anyone know how a unilateral thalamic lesion would present besides the sensory loss?

Visual and auditory dysfunction (LGN, MGN), wernicke-korsakoff's sydnrome (dorsomedial nucleus) , motor dysfunction (centromedian nucleus, VA/VL)