History and Physical — Patient 46

History

Present Illness: A 68 year old woman presents with progressive hearing loss and gait difficulties over the past 1.5 years. Approximately 1.5 years ago, she noted hearing loss in her right ear which rapidly progressed to involve her left ear over the ensuing months. An otologic evaluation revealed bilateral hearing deficits, primarily to high frequency sounds. Hearing aids were marginally helpful, and hearing loss quickly progressed to the point where even normal conversation was difficult to hear. The patient also reports mild unsteadiness while walking over the past 1.5 years, worsening slightly over this time period, though not resulting in falls or interfering with daily activities. She denies focal weakness, sensory abnormalities, worsening of her gait at night or in darkness, visual symptoms, coordination difficulties, headache, tinnitus, or vertigo.

Past Medical History: Rheumatic fever with heart involvement as a child, asymptomatic since then. Trauma from a motor vehicle accident in the 1970's with no loss of consciousness, but some chronic neck pain and possibly a "mild fracture" of a vertebra (per husband's account).

Past Surgical History: Suboccipital craniotomy for undocumented reasons in 1968 (records no longer available)—the patient and her husband described symptoms of headache and decreased visual acuity, being told that surgery was necessary to treat these symptoms, and that no tumor was found at the time of operation. Her symptoms completely resolved within weeks to months after the surgery. Total abdominal hysterectomy and bilateral oophorectomy in 1989, for fibroids.

Allergies: No known drug allergies.

Medications: None.

Family History: The patient's mother had sensorineural deafness which began at approximately age 55 and required hearing aids later on in her 80's. Her father had coronary artery disease and a brother has brain cancer (details unknown).

Social History: Retired teacher; married; no history of tobacco, alcohol or drug use.

Review of Systems: Unintentional 11 pound weight loss over the past year—evaluation for occult malignancy, done by her primary care physician, was negative. Some symptoms of depression, such as difficulty sleeping, and anxiety, but in the past did not tolerate separate trials of trazodone and buspirone.

Physical Exam

General: Well-nourished, well-developed pleasant lady resting comfortably.

Vital Signs: Temperature 97.5 F; pulse rate 72, regular; respiratory rate, 16/min; blood pressure 148/92 mmHg.

HEENT: Normocephalic; suboccipital craniotomy scar; sclerae anicteric; oropharynx clear.

Neck: Supple; no carotid bruits.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Regular rate and rhythm with systolic ejection-type murmur at the apex.

Abdomen: Soft, nontender, and nondistended. No organomegaly.

Extremities: No cyanosis, clubbing or edema. No bruises, telangiectasias, angiomas, rashes, or other skin lesions.

Neurological Examination

Mental Status: Awake and alert. The patient scores 26/30 on the Folstein Mini-Mental Status Examination (-1 registration, -2 spelling "world" backwards, -1 intersecting pentagons).

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIThe pupils are equally round and reactive to light. Visual fields are intact to confrontation.
III / IV / VIThere is full range of motion on extraocular movements, without nystagmus.
VPinprick and light touch are intact and symmetric in all divisions of the face. Corneal reflexes are present bilaterally. Intact masseter and temporalis strength.
VIIFacial movements symmetrical with normal lip seal and eye closure.
VIIIUnable to hear finger rubs even with hearing aids, but able to hear tuning fork.
IX / XPalate elevates symmetrically, uvula midline.
XISternocleidomastoid strength 5/5.
XIIMidline tongue protrusion without atrophy or fibrillations.

 

Motor: Normal tone and bulk. Strength 5/5 throughout and symmetrical in all muscle groups tested.

Reflexes: Biceps, triceps, brachioradialis, patellar, and Achilles 2+ and equal bilaterally. No crossed adduction; plantar responses are flexor. Absent Hoffmann's, jaw jerk, glabellar, snout and palmomental reflexes.

Sensation: Pinprick, light touch, vibration, and temperature intact. Proprioception is minimally impaired at distal toes and fingers bilaterally. Romberg negative.

Cerebellar: Finger-nose-finger shows very mild end-point dysmetria on the left, intact on the right. Mild dysmetria on heel-to-knee-to-shin maneuver on the left, intact on the right. Normal rapid alternating movements. No significant truncal ataxia. Minimal loss of check of flexion movements bilaterally.

Gait: Slightly wide based and cautious, but not unsteady or ataxic. Able to toe, heel and tandem walk, though mild difficulty on tandem walking.

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