Sudden, Severe Upper Limb Pain and Weakness in a Sleepless Man

Olusegun John Oluwole, MBBS


December 14, 2020

Physical Examination and Workup

Upon examination, the patient is oriented, appears well nourished, and is not pale. He is afebrile, with an axillary temperature of 98.6 °F (37 °C). His hydration status is good, and he has no pitting leg edema. His respiration rate is 16 breaths/min, with vesicular breath sounds over the lung fields and no adventitious sounds. His radial pulse is regular and of normal volume, with a rate of 80 beats/min. Blood pressure taken in the supine position is 124/74 mm Hg in his right arm. Jugular venous pulsations are normal, and the cardiac apical pulsation is not displaced. He has normal S1 and S2 heart sounds, with an apical S4 heart sound but no murmurs. His abdomen is full and moves with respiration. It is soft to palpation, and no palpable organ enlargement is noted. Bowel sounds demonstrate normal activity.

Upon neurologic examination, he is awake, aware, and coherent; answers appropriately to questions; and has no lapses in memory or language. He has no signs of meningeal irritation. His pupils are round, mid-sized, and reactive to light. His visual fields are normal by confrontation, and his optic discs are clear. He has full range of ocular movements, with normal saccades and smooth pursuit.

Results of a cranial nerve examination are normal, including facial sensation and movements, jaw strength, and tongue movements. The left arm shows remarkable weakness in shoulder abduction of grade 2/5, shoulder flexion of grade 1/5, and shoulder external rotation of grade 1/5. Shoulder shrug, elbow flexion-extension, elbow pronation-supination, wrist flexion-extension, finger flexion-extension, and finger abduction-adduction are preserved.

Slight wasting of the left supraspinatus and deltoid muscles is evident. Pinprick testing demonstrates diminished sensation in the skin overlying the left deltoid muscle and the lateral forearm. Biceps and supinator jerks are blunted. The opposite upper extremity and both lower limbs show normal muscle strength in all groups, normal deep tendon reflexes, and normal sensation, except for a slightly decreased pinprick sensation in both feet in a stocking distribution.

Upon provocative testing, the Phalen test result is positive in both wrists, but no Tinel sign is noted at the usual nerve entrapment sites in the upper and lower limbs. The plantar reflex causes a downward response bilaterally. His gait is unimpaired, and Romberg test results are negative. The cervical spine shows normal active and passive range of motion in all directions, and no axial tenderness is noted over the spinous processes or the adjoining facet joints. The cervical paraspinal muscles are not unduly tender. Upon shoulder joint examination, palpation of the left shoulder does not elicit any tenderness. Passive shoulder abduction does not lead to aggravation of pain, and no resistance or impingement is encountered.

Results of these laboratory investigations are all normal: complete blood cell count, erythrocyte sedimentation rate, C-reactive protein level, electrolyte levels, and kidney and liver function tests. A urine dipstick measurement shows glycosuria of 1+. A random blood glucose measurement is 185 mg/dL, and the A1c concentration is 8%. Results of the cervical spine MRI are shown in the figures below.

Figure 1.

Figure 2.


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