NURS 6512 Week 10 Neurological Localization Note Example

Localizing Three Weeks of Left Hand Numbness and Clumsiness in a 54-Year-Old Right-Handed Woman

Student Name

College of Nursing, Walden University

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Instructor Name

Month Day, Year

Localizing Three Weeks of Left Hand Numbness and Clumsiness in a 54-Year-Old Right-Handed Woman

Subjective

M.A. is a 54-year-old right-handed bookkeeper whose case was built for this exercise and matches no actual patient. She reports three weeks of numbness and tingling in her left hand, which she localizes by running a finger along the thumb, the index finger, and the outer edge of her forearm to just below the elbow. The symptoms began gradually after a weekend spent repainting a ceiling. She also notices that her left hand is "clumsy": she has dropped a coffee cup twice and has trouble opening jars. She reports aching pain at the base of the left side of her neck, spreading over the top of the shoulder, which is worse when she looks up or turns her head to the left and eases when she rests her left hand on top of her head.

She denies symptoms in the right hand or either leg, and she has had no change in gait or balance, no bladder or bowel change, no headache, no visual disturbance, no difficulty speaking or swallowing, and no facial numbness. The tingling does not wake her at night and is not worse with typing or driving. She has hypothyroidism treated with levothyroxine and no history of diabetes, neck injury, or neck surgery. She does not drink alcohol to excess.

Objective

Mental status and cranial nerves

She is alert, oriented, and attentive, with fluent speech and intact comprehension. Cranial nerves II through XII are intact, including symmetric facial sensation and strength, full extraocular movements, and a midline tongue.

Motor and reflex detail

Muscle bulk is symmetric with no atrophy or fasciculations. Tone is normal in all four limbs. There is no pronator drift. Strength is graded on the Medical Research Council scale muscle by muscle (Bickley et al., 2021).

Left upper limb: deltoid 5, biceps 4, brachioradialis 4, wrist extensors 4, triceps 5, wrist flexors 5, finger flexors 5, finger abductors 5, abductor pollicis brevis 5. Right upper limb: 5 in every muscle tested. Lower limbs: 5 throughout.

Reflexes are graded bilaterally: biceps 1+ on the left and 2+ on the right, brachioradialis 1+ on the left and 2+ on the right, triceps 2+ on both sides, knee and ankle jerks 2+ and symmetric. Hoffmann's sign is absent on both sides, plantar responses are flexor, and there is no ankle clonus.

Sensory map

Light touch and pinprick are reduced over the lateral forearm, the thumb, and the index finger of the left hand on both palmar and dorsal surfaces. Sensation is normal over the middle, ring, and little fingers, the medial forearm, and the upper arm. Vibration at the fingertips and joint position sense are intact on both sides. The sensory change extends proximal to the wrist and covers the dorsum of the thumb, which lies outside the territory of the median nerve in the hand.

Coordination, gait, and provocative tests

Finger to nose and rapid alternating movements are accurate on both sides, with the left slightly slower, in keeping with weakness rather than ataxia. Gait, tandem gait, and Romberg are normal. The Spurling maneuver, extension and rotation of the neck to the left with gentle axial pressure, reproduces her arm tingling. Neck distraction relieves it. Tinel's sign at the left wrist and Phalen's maneuver for 60 seconds are both negative, and elbow flexion does not provoke symptoms.

Localization, Level by Level

Cerebral cortex and subcortical pathways: inconsistent. A cortical or subcortical lesion causing hand weakness would usually bring upper motor neuron signs, such as brisk reflexes, increased tone, or pronator drift, and often facial or language involvement. None are present, and the reflexes in the affected arm are reduced rather than increased.

Spinal cord: inconsistent. A cervical cord lesion would be expected to produce upper motor neuron signs below the level, such as a positive Hoffmann's sign, brisk leg reflexes, or an extensor plantar response, and often gait or bladder change. All are absent.

Nerve root: consistent. The combination of weakness in biceps, brachioradialis, and wrist extensors, reduced biceps and brachioradialis reflexes, sensory loss over the lateral forearm, thumb, and index finger, and neck pain reproduced by the Spurling maneuver and relieved by distraction and by resting the hand on the head, points to the left C6 root. In a study of clinical tests for cervical radiculopathy, a cluster that included a positive Spurling test and relief with distraction substantially increased the likelihood of radiculopathy (Wainner et al., 2003).

Brachial plexus: incompletely tested but unlikely. An upper trunk lesion could produce similar weakness, but it would usually also weaken the deltoid and the shoulder rotators, and it would not be provoked by neck movement.

Peripheral nerve: inconsistent. Median nerve compression at the wrist would spare the forearm and the biceps reflex, weaken the thumb abductor rather than the wrist extensors, and usually produce night symptoms and a positive Phalen's maneuver (Padua et al., 2016). Radial and ulnar nerve patterns do not fit the distribution.

Differential from the Level

With the lesion placed at the left C6 root, the differential is limited to processes that affect a cervical root. The leading diagnosis is left C6 radiculopathy from a C5-C6 disc herniation, supported by the onset after sustained neck extension, age, and the dermatomal and myotomal pattern. Foraminal stenosis from cervical spondylosis is the second possibility and is common at this age, though it tends to develop more slowly. Less likely root-level causes include an inflammatory or infectious radiculitis, such as herpes zoster before the rash appears, and, rarely, a mass compressing the root. Carpal tunnel syndrome and a central lesion were considered and set aside for the reasons given above. Most cervical radiculopathy improves with conservative care, and imaging is generally reserved for progressive weakness, myelopathic signs, or failure to improve (Iyer & Kim, 2016).

The finding that would most change this localization is the reflex examination. If her biceps reflex were brisk rather than reduced, or if Hoffmann's sign were present, the lesion would move from the root to the cervical cord, and magnetic resonance imaging would become urgent rather than elective.

Plan

Because the weakness is mild, stable, and confined to one root, with no sign of cord involvement, the plan is conservative and time-limited. She is advised to avoid sustained neck extension, including overhead painting and looking up at a high monitor, and to use a short course of an over-the-counter nonsteroidal anti-inflammatory drug with food if she has no contraindication. Referral to physical therapy is made for posture, cervical mobility, and graded strengthening of the affected muscles. A thyroid-stimulating hormone level is checked, since her hypothyroidism is a treatable contributor to neuropathic symptoms if it is undertreated, although it would not explain a single-root pattern on its own.

She is taught what would change the plan: weakness that spreads or worsens, numbness that appears in the other hand or in either leg, a change in walking or balance, or any new difficulty controlling her bladder or bowels. Any of these should bring her back the same day. Otherwise the examination is repeated in four to six weeks, with strength graded in the same muscles and reflexes recorded the same way so that change can be measured rather than estimated. If she has not improved by then, or if the weakness has progressed, magnetic resonance imaging of the cervical spine and electrodiagnostic testing would be the next steps.

References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Iyer, S., & Kim, H. J. (2016). Cervical radiculopathy. Current Reviews in Musculoskeletal Medicine, 9(3), 272-280. https://doi.org/10.1007/s12178-016-9349-4

Padua, L., Coraci, D., Erra, C., Pazzaglia, C., Paolasso, I., Loreti, C., Caliandro, P., & Hobson-Webb, L. D. (2016). Carpal tunnel syndrome: Clinical features, diagnosis, and management. The Lancet Neurology, 15(12), 1273-1284. https://doi.org/10.1016/S1474-4422(16)30231-9

Wainner, R. S., Fritz, J. M., Irrgang, J. J., Boninger, M. L., Delitto, A., & Allison, S. (2003). Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine, 28(1), 52-62. https://doi.org/10.1097/00007632-200301010-00014