History and Physical — Patient 38

History

Present Illness: The patient is a 39 year old African-American female with chronic microcytic anemia who presented to the urgent care clinic of the Houston Veterans' Administration Medical Center, complaining of a 6-7 month history of left lower extremity weakness and numbness, accompanied by left-sided abdominal pain.

In October 1998, she first noticed spasms in her left leg, especially when lying down. At that same time, she also experienced the onset of left leg numbness. In early November 1998, the patient developed difficulty with walking, attributed to left leg weakness. By late November, she began to drag her left leg when walking, and was forced to quit her job as a waitress because of inability to "keep up at work." Around that same time, she began to experience pain in her left side, which she described as sharp and lancinating in character. By December, she was having balance problems, especially in the dark. The numbness in her leg worsened, and by February 1999, she reported that her left leg was completely numb to the level of the hip. She describes the numbness in her left leg as complete loss of sensation, but does report painful sensations of "pins and needles" in the left foot when she puts on a sock. Subsequently, the pain she was experiencing in her left side began to extend down her left leg. She described this pain as dull, achy and constant. She denied any throbbing, shooting or radiating pain, as well as any pain on her right side. Concomitantly with the worsening of her sensory symptoms, the spasms and weakness in her left leg became more severe.

The patient also reports a band-like area of numbness and tightness around her mid-abdomen that has persisted for several months. She also is occasionally incontinent of urine, with incomplete urinary emptying and increased frequency of urination. She also reports significant constipation; at the time she was seen, she reported no significant bowel movements for eight days.

The patient has a long-standing history of severe constipation related to consumption of clay from her hometown in Mississippi. This clay is dried and then eaten. She states that her consumption of clay had increased recently, owing to stress from her symptoms of weakness.

The patient was hospitalized in April 1999 for a total abdominal hysterectomy to treat fibroids with severe uterine bleeding. Until that time, she had attributed her weakness and pain to the fibroids and to anemia. Following her surgery, her symptoms, which had not improved, were discussed with her surgeon, who recommended neurology consultation. The patient presented approximately three weeks later for evaluation, at which time she denied any symptoms in the right leg or either arm, as well as dysphagia, dysarthria, and vision changes.

Past Medical History: Hypermenorrhea and hypermenorrhagia with microcytic anemia attributed to this blood loss. She has never required blood transfusions. She underwent bilateral tubal ligation in 1991 and hysterectomy in April 1999, without known perioperative complications.

Allergies: Allergies: No known drug allergies.

Medications: Multivitamin and iron supplementation.

Family History: Coronary artery disease and peripheral vascular disease in mother and siblings. Her father died from unknown causes. There is no known history of neurologic disease in the family, and no family history of sudden death, hemorrhage, or unexplained hospitalization or institutionalization.

Social History: Separated, with 1 daughter. She was born and raised in rural Mississippi, with a high school education. She worked as a waitress at one of the Houston airports previously. There is a 10 pack year history of tobacco use and a remote history of cannabis use, but no history of alcohol use. The patient has a lifelong history of clay ingestion, which is shared by numerous other female members of her family. The patient reported that she would intermittently cease eating clay when her constipation became very bad or she was found to be very anemic.

Review of Systems: Approximately 10 pound weight loss over the past year.

Physical Exam

General: Thin African-American female in no acute distress when examined.

Vital Signs: B.P. 120/70; pulse 76; temperature 99.0 F; respiration 18.

HEENT: Normocephalic without evidence of trauma. Normal funduscopic examination, acuity, and visual fields. Oropharynx clear. Neck supple without lymphadenopathy.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Regular rate and rhythm; no murmurs.

Abdomen: No masses palpated; no hepatosplenomegaly. Normoactive bowel sounds. No abdominal bruits ausculted. Stool was guaiac negative.

Extremities: No cyanosis, clubbing or edema. No skin lesions evident. Normal peripheral pulses.

Neurological Examination

Alert, fully oriented. Speech fluent, comprehension intact. Cranial nerves 2-12 fully intact. Motor exam revealed normal tone but decreased bulk throughout. No fasciculations were noted. Strength in both arms and the right leg was 5/5 on the MRC scale. The left iliopsoas and quadriceps had 2/5 strength; knee flexors as well as dorsiflexion of the ankle were 3/5.

The sensory exam in the arms showed intact pinprick, light touch, temperature, vibration and proprioceptive sensation. Both legs had decreased sensation to pinprick, light touch, temperature and vibration throughout with dysasthesias noted on the L lower extremity when tested. The patient had a sensory level at T4, more marked on the left than the right, with dysesthesias also noted on testing of her back. Cerebellar exam revealed normal finger-to-nose and rapid alternating movements. Further evaluation of lower extremity coordination was compromised by weakness. Tendon reflexes: 1+ in arms bilaterally, 1+ in the right leg, 2+ in the left leg. Plantar response was extensor on the left, and absent on the right. No Hoffman's sign was present. Gait was unsteady and wide-based, with dragging of the left leg.

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