History and Physical — Patient 3

History

Patient #3 is a 59 year old female who noticed progressive weakness in her lower extremities beginning one year ago. Numbness in the legs was noted approximately six months later and worsened significantly two months ago prompting her to seek help from a Neurosurgeon. Reportedly, an imaging study done at that time revealed a C5/6 disc bulge and the patient underwent a cervical laminectomy. Postoperatively the patient did not improve and actually got worse with increasing weakness and numbness in the legs, becoming wheelchair bound with severe incontinence of bowel and urine.

Patient #3 sitting

Patient #3 sitting

She gave a past history of arthritis and 5 surgeries (hysterectomy, oophorectomy, hiatal hernia, rt. breast lumpectomy, and a cervical laminectomy two months ago). The family history is negative for neurological disease. She is married with two children and does not smoke or have a history of drug use. She is an occasional social drinker.

Physical Exam

Normal other than rectal exam which revealed decreased sphincter tone.

Neurological Examination

Mental Status: Alert, oriented, mini-mental status 27/30, speech fluent.

Cranial Nerves: I-XII normal.

Motor: All muscles groups of the upper extremities were normal (5/5) with the exception of the interossei of both hands (4/5). In the lower extremities definite weakness was present: Iliopsoas 2-3/5; Quadriceps 2/5; Hamstrings 2/5; Tibialis Anterior 2/5; Gastrocnemius: 2/5.

Reflexes: 2+ upper extremities; 0 lower extremities.

Sensation: Upper extremities: normal. Lower extremities: 1) decreased sensation to pinprick and touch to midthigh regions bilaterally 2) decreased sensation to pinprick in sacral areas 3) decreased proprioception & vibration in toes and ankles.

Coordination: Intact in upper extremities on finger-to-nose with no dysmetria or dysdiadochokinesia. Heel to shin difficult to assess due to weakness.

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