History and Physical — Patient 58

History

Chief Complaint: Leg stiffness and gait disturbance

Present Illness: The patient is a 51 year old right handed truck driver presenting to the Neurology Service of the Houston Veterans Administration Medical Center for evaluation of 3 years of unremittingly progressive bilateral leg stiffness and weakness. His illness began with slowly progressive tingling and numbness in the feet and hands for about one year, associated with mild right hand weakness. His gait has subsequently deteriorated to wheelchair dependency. He occasionally has bowel or bladder incontinence that he relates to inability to reach the bathroom. He has never required catheterization and has had no history of urinary tract infections. He has experienced two episodes of horizontal diplopia lasting up to 30 days, the first occurring 2 years after the onset of his symptoms, and the second occurring in the month prior to admission. He also complains of generalized fatigue. None of his symptoms are clearly exacerbated by temperature fluctuations.

The patient was evaluated by physicians prior to his presentation to the Neurology Service. According to laboratory studies from the year prior to admission, he has electrodiagnostic evidence of an axonal neuropathy, without a documented cause. He has been treated with muscle relaxants, with modest benefit.

Past Medical History:

  • Gastroesophageal reflux disorder.
  • Depression.
  • Blood transfusion 15 years ago.
  • Cigarette smoking, one pack per day for 25 years.

Past Surgical History: Nasal repair s/p trauma, left knee arthroscopy, right fibula fracture two years ago, repair of knife wound to the left wrist.

Medications: Fluoxetine 20 mg q.d., methocarbamol 750 mg t.i.d., baclofen 10 mg t.i.d., simethicone 80 mg t.i.d., acetaminophen 325 mg q6 hr as needed.

Family History: The patient is adopted, and does not have detailed knowledge of his family history. He has a fraternal twin with no known neurological disease.

Social History: He is a widower, living in the Greater Houston area. There is no history of travel to other countries.

Review of Systems: The patient denies headache, chest pain, shortness of breath, orthopnea, or abdominal pain. He denies recent significant weight loss.

Physical Exam

General: Well developed and nourished male in no distress.

Vital Signs: Temperature = 98.3 F, blood pressure = 121/75 mmHg, pulse = 65/min and regular, respirations = 16/min.

HEENT: Normocephalic, no evidence of head trauma. Sclerae anicteric, oropharynx clear.

Neck: Supple with full range of motion, no cervical adenopathy, no jugular vein distention.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops.

Abdomen: Soft, normoactive sounds, nontender. No organomegaly noted.

Extremities: Dry lower extremity skin, onychomycosis of toenails, good dorsalis pedis pulses. No clubbing, cyanosis, or edema.

Neurological Examination

Mental Status: Alert, pleasant and cooperative. Folstein Mini-Mental Status Exam score 30/30.

Speech: Normal labial, lingual and guttural sounds. Normal comprehension, repetition, and speech fluency.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
II20/20 vision bilaterally by near card testing; full visual fields to confrontation; pupils equally round and reactive; no Marcus Gunn phenomenon detected; normal fundoscopic exam.
III / IV / VIHe has a right VI palsy with horizontal diplopia evoked by gaze to the right.
VIntact to light touch, pin prick and temperature in all three divisions bilaterally.
VIISymmetric muscles of facial expression without definite weakness.
VIIIHearing intact to finger rubs, air conduction > bone conduction by 512 cps tuning fork.
IX / XUvula midline with symmetric palatal elevation.
XIIntact sternocleidomastoid strength bilaterally.
XIITongue strength intact, with midline protrusion; no atrophy or fibrillations.

 

Motor: Normal muscle bulk, with increased tone in the right upper extremity, atrophy in the anterior and posterior leg muscles together with increased tone, and contractures at the ankles. Right upper extremity strength 5/5 proximally, 4/5 distally. Left upper extremity strength 5/5 throughout. Bilateral lower extremity strength: Iliopsoas 3/5, quadriceps 4/5, knee flexion 2/5, ankle dorsiflexion 3/5, ankle plantarflexion 4/5.

Reflexes: The jaw jerk is accentuated. Tendon reflexes are 3+ (showing distal spread) at biceps, triceps, and brachioradialis bilaterally, with Hoffman signs present. Patellar tendon reflexes are 3+. Achilles reflexes are 4+ with sustained ankle clonus. Babinski responses are present bilaterally.

Sensation: Decreased to vibration and proprioception in the legs. There are subtle sensory hemilevels to pinprick stimulation in the T6 to T9 region.

Coordination: Intact finger-nose-finger, fine finger movements, and rapid alternating wrist/hand movements. Heel to shin maneuvers are performed slowly but proportionally to weakness.

Gait: Spastic gait. The patient walked 50 feet in 60 seconds.

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