History and Physical — Patient 32
Present Illness: Patient # 32 is a 22 year old African-American female without significant PMH who presented with complaints of weakness of both legs and frequent falls. Three months prior to presentation she began to experience bilateral lower extremity weakness. Initially, she noticed clumsiness when walking that progressed to frank weakness. She also noticed intermittent diplopia as well as urinary incontinence. Approximately one week prior to presentation her symptoms worsened with both vertical and horizontal diplopia, dysarthria, increased weakness of both legs and arms, and falling when attempting to walk. On the day of presentation she experienced three episodes of urinary incontinence and one episode of bowel incontinence.
She denied fever, chills, night sweats, diarrhea, recent flu-like symptoms, rash, dysphagia, parasthesias, seizures, loss of consciousness, or fasciculations. She did complain of bilateral leg cramps and a 30 lb. weight gain which she attributed to decreased activity and increased eating. She also had one episode of shortness of breath following a hot shower.
Past Medical History: PID treated with intravenous antibiotics one month prior to admission.
Past Surgical History: None.
Allergies: No known drug allergies.
Family History: No neurological diseases.
Social History: No tobacco, alcohol, drug abuse; she works as a receptionist.
General: Pleasant African-American female who is well-developed and well-nourished in no apparent distress.
Vital Signs: B.P. 94/47; pulse 60; temperature 98.8 F; respiration 18.
HEENT: NCAT; anicteric sclerae; fundus - bilateral sharp optic discs; oropharynx clear; neck supple without thyromegaly or lymphadenopathy.
Chest: Clear to auscultation and percussion bilaterally.
Cardiovascular: RRR; normal S1/S2; no rubs, gallops, or murmurs appreciated.
Abdomen: Soft, nontender, nondistended, normal bowel sounds.
Extremities: No cyanosis, clubbing, or edema.
Skin: No rashes or lesions.
Mental Status: Awake, alert and oriented to person, place, and time; attention is grossly intact; speech shows frank dysarthria including labial, lingual and guttural consonants; language shows intact comprehension, repetition, naming, reading, and writing; short-term memory is intact.
|II||PERRLA, VF intact to confrontation, VA not assessed.|
|III / IV / VI||Bilateral upgaze palsy; L lateral gaze palsy; no nystagmus.|
|V||LT/PP intact V1-V3, masseter strength normal.|
|VII||No asymmetry or weakness, positive for psuedobulbar affect.|
|VIII||Hearing intact to bilateral finger rub.|
|IX / X||Gag intact bilaterally, palate rises symmetrically, uvula midline.|
|XI||SCMs 5/5 bilaterally.|
Motor: Normal bulk without fasciculations; tone increased throughout; spastic.
Reflexes: 3+ to 4 throughout. Babinski's and Hoffman's signs are present bilaterally; there are bilateral crossed adductors at the knees.
Sensation: There is a sensory level at T6-7 for T/PP/LT. Proprioception is intact in the distal extremeties. There is, however, a loss of body position sense bilaterally.
Cerebellar: Exam confounded by weakness and spasticity. Decreased rate and rhythm of RAM's.
Gait: Requires constant support; gait is wide based and spastic with a component of gait apraxia as well.