Case History:

43 yo Hispanic female presented with a rash

Contributed By:
John H. Riggs III, MBA, DC, FACO
Case Presentation: Page 2 of 6

Some of the diagnoses you should consider includes:  Amyotrophic Lateral Sclerosis (ALS), multiple sclerosis, herniated cervical nucleus pulposus, and spinal cord tumor.

Physical Exam Findings: 

Visual examination demonstrated a papular rash on the muscle aches and trunk but not face.  There was severe wasting of the intrinsic muscles of the left hand on both dorsal and palmar aspects presenting as a claw hand.  There was slight flattening of the left side of the facial musculature.  The left hand demonstrated a pronounced tremor with a slight tremor in the right hand.  She had foot drop on the left with steppage gait with ambulation and difficulty flexing the hip requiring her to walk with a pelvic swing through-like motion.  She required assistance to ambulate.

Orthopedic and neurological testing revealed DTRs were 2+ except the left patellar which was asymmetric with 3+ and clonus.  Manual muscle testing revealed absent grip strength on the left with only slight grip strength on the right with finger squeeze.  Her hip flexors on the left and the left foot and ankle dorsiflexion and plantarflexion were 3/5.  Cranial nerve testing was unremarkable.  Both UMN and LMN signs were demonstrated. 

Question:  What is your working diagnosis for this case?

Question:  What diagnostic imaging studies would you order?  Laboratories?

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