History and Physical — Patient 18

History

Patient #18 is a 47-year-old female who presented with the complaint of a two day history of difficulty in expressing herself and problems with concentration and short-term memory. She also described a one and one-half year history of progressive bilateral extremity numbness and gait difficulty. Her symptoms were of gradual onset, and included numbness and intermittent tingling in her hands and feet. Her gait difficulty was described as "unsteadiness" that worsened in the dark. She had been walking with the assistance of a walker for six months.

She also reported an episodic shooting pain that started in her neck and passed down her back and into both arms. She denied any history of previous trauma, diplopia, dysphagia, vertigo, vision loss, loss of consciousness, back pain, or symptoms of bowel or bladder dysfunction.

Family history was negative for neurological disease. Her medications included only an occasional anti-inflammatory drug for neck pain. Social history revealed a one-half pack per day history of tobacco use, social alcohol ingestion, and no illicit drug use. She was single and worked as a security dispatcher.

Physical Exam

Vital Signs: T-98.2, HR-68, B/P-110/60, R-18.

HEENT: Normocephalic, atraumatic; oropharynx clear.

Neck: Supple; no lymphadenopathy; no audible bruits; no thyromegaly.

Musculoskeletal: No spine or costovertebral angle tenderness.

Chest: Clear to auscultation.

Cardiovascular: Regular rate and rhythm; no murmurs.

Abdomen: Soft; nontender; no organomegaly.

Rectal: Normal rectal tone; stool guaiac negative.

Extremities: No clubbing, cyanosis, or edema.

Skin: No rash.

Neurological Examination

Mental Status: Awake and cooperative. Response time was somewhat slowed. Mini-mental exam 26/30 (missed three points on serial 7 subtraction and was unable to recall one of three objects at five minutes). Speech was fluent with no evident dysarthria.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIVisual acuity 20/25 in both eyes (corrected); Normal funduscopic exam; Pupils equal, round, and reactive to light with no afferent pupillary defect; Visual fields intact with no central scotoma.
III / IV / VIExtraocular movements intact.
VIntact facial sensation; Intact masseter motor strength.
VII - XIIntact.
XIITongue protruded in midline; No fibrillations seen.

 

Motor: Normal bulk of muscles. Increased tone in lower extremity muscles. Muscle strength 5/5 in all muscle groups with the exception of 4/5 in the iliopsoas muscles, bilaterally.

Reflexes: Reflexes were 3+/4 bilaterally in the biceps, triceps, brachioradialis, and patellar and 2+/4 in the ankles. Plantar responses were upgoing bilaterally. No ankle clonus or hyperactive jaw jerk.

Sensation: Diminished pinprick sensation in a stocking-and-glove distribution (to wrist and to ankles). Vibration and proprioception sense loss in both lower extremities from the waist down. Romberg test showed patient able to stand with feet together with eyes open, but unsteady with eyes closed.

Cerebellar: Normal finger-to-nose, heel-to-shin, and rapid alternating movements.

Gait: Slow, cautious, unsteady wide-based gait. With each step, the foot was thrust outwards and made an audible slapping sound as it struck the floor.

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