Author: Ndeye Guisse, BS
Co Author #1: Matt Margol, BS
Co Author #2: Oluseun Olufade, MD
Co Author #3: Mathew Pombo, MD
Senior Editor: Margaret Gibson, MD, FAMSSM

Patient Presentation:
The patient is a previously healthy 42-year-old healthcare coder and biller who presented to an outside clinic with left shoulder and arm numbness and weakness.

History:
Her symptoms began in early 2018 with nonspecific numbness in her left hand treated conservatively for carpal tunnel syndrome. This failed to alleviate her symptoms which extended up her arm into her elbow and shoulder. In late 2018 she woke up with massive swelling and warmth in her left shoulder and deltoid region. She went to the emergency room where she was diagnosed with a 1.5 cm Chiari I malformation and syringomyelia to the T9 thoracic level and chronic bony erosions and fluid collections in her left shoulder. In February 2019 she underwent surgical repair of the malformation and syrinx fluid drainage but symptoms remained. She presented for a second opinion with continued lack of function in her left upper extremity.

Physical Exam:
Vitals: Afebrile, vital signs stable and within normal limits.
General: Well-nourished, well developed, in no apparent distress.
Neck: Nontender, with full range of motion. No masses.
Musculoskeletal: Left shoulder exam revealed a flaccid shoulder with no forward flexion, external rotation, or internal rotation. Shoulder abduction was at 20 degrees. She had full flexion, extension, and rotation of her elbow and wrist. She had 5/5 strength in her wrist and hand. Sensation was intact to the left upper extremity. Normal and symmetric pulses were noted.

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