History and Physical — Patient 66


Chief Complaint: Bilateral lower extremity weakness.

Present Illness: The patient is a 73-year-old black female with monoclonal gammopathy of unknown significance, osteoporosis, and degenerative disease of the spine, who was admitted to The Methodist Hospital for evaluation of weakness and difficulty ambulating. Her weakness began insidiously and progressed, necessitating the use of a walker for ambulation for the past 4-6 weeks. In the past 4-5 days, she developed increasing weakness in the lower extremities, and began to note upper extremity weakness. On the day of hospital admission, she was unable to stand without assistance. She had complained of shooting pains down the back of her legs for 2-3 months, had recently undergone myelography, and had been advised by a physician that she could possibly benefit from back surgery. She was placed on gabapentin 1 1/2 weeks ago, which reduced her pain. She also complained of some numbness in her thighs. Over the past few days she has been unable to completely open her mouth. She denied any choking spells, difficulty breathing, diplopia, or bowel or bladder incontinence.

Past Medical History:

  • Hypertension
  • Osteoporosis with multiple vertebral fractures
  • Lumbar disc disease (post lumbar discectomy 13 years ago)
  • Monoclonal gammopathy of unknown significance, periodically reviewed
  • Possible peripheral neuropathy (not otherwise specified)
  • A febrile pulmonary illness of unknown cause over ten years ago, responsive to steroids, and now in remission
  • History of sudden onset left-sided hearing loss and tinnitus six years ago
  • Possible stroke in the past (not otherwise specified, and patient does not recall symptoms)
  • Chronic diarrhea of unknown cause several years ago, that remitted and is not currently active
  • Dysfunctional uterine bleeding three months ago, with negative uterine biopsy
  • Mild chronic renal insufficiency

Allergies: Sulfa compounds.

Medications: Gabapentin 200 mg tid, daily aspirin, multivitamin tablets, ticlopidine, alendronate, guanabenz, calcium supplements, estradiol/norethindrone tablets

Social History: Quit tobacco smoking twenty years ago, and rare alcohol intake.

Family History: Negative for any neurologic illness.

Review of Systems: Notable for mild, chronic dry cough; otherwise unremarkable. No symptoms of dry eyes or mouth. No recent abdominal complaints or diarrhea. No history of leg edema or rash. No recent skin changes.

Physical Exam

General: Well-nourished, elderly black female appearing fatigued, but in no acute distress.

Vital Signs: Temperature 97.9 F, pulse 67/min, regular, blood pressure 111/60 mm Hg, respirations 16/min, unlabored.

HEENT: Sclerae anicteric, conjunctivae pink. Oral cavity without lesions. Moist mucous membranes. Jaw opening less than two cm, with a degree of masseter spasm.

Neck: Supple, without lymphadenopathy or masses. No carotid bruits or jugular venous distention. No thyromegaly.

Chest: Clear to auscultation.

Cardiovascular: Regular rate and rhythm with no murmur, rub or gallop heard.

Abdomen: Soft, nontender, nondistended, bowel sounds present, no hepatosplenomegaly.

Skin: On skin examination, no rashes, skin lesions, depigmentation, pitting, thickening, or other abnormalities were noted.

Extremities: No cyanosis, clubbing or edema. + soreness to palpation of muscles in anterior thighs and calves.

Neurological Examination

Mental Status: Alert and cooperative. Oriented to person, place, time and situation. Conversant, with full language comprehension.

Cranial Nerves: Pupils equally round and reactive to light. Extraocular movements intact. Facial sensation intact to to pinprick, light touch and temperature. Face symmetric with full strength; masseter spasm as previously noted. Decreased hearing in the left ear. Weber midline. Rinne positive bilaterally. Palate symmetrically elevates. Sternocleidomastoid muscles with full strength. Tongue protrudes midline and has good mobility.

Motor: Normal tone with no fasciculations or atrophy.




Upper Extremities

Wrist Extensors5-5
Wrist Flexors35
Finger Extensors45
Finger Flexors4-5

Lower Extremities

Knee Extensors4-5
Knee Flexors4-5
Ankle Dorsiflexors45
Ankle Plantarflexors4+5


Reflexes: 1/4 in bilateral biceps, triceps and brachioradialis. Trace in left patellar. Absent in right patellar, and absent ankle jerks bilaterally. Hoffman's sign is negative. Plantar responses are flexor bilaterally. Jaw jerk response is absent.

Sensation: Decreased to pinprick, light touch, temperature, vibration distal to knees and wrists bilaterally. Proprioception minimally impaired. Decreased sensation to pinprick and temperature in anterolateral aspect of thighs bilaterally.

Coordination: Intact finger-to-nose and rapid alternating movements. Could not perform heel-to-shin secondary to weakness and fatigue.

Gait: Requires full assistance to stand. Unsteady, cautious symmetric gait using a walker. Able to take 5-6 steps with walker.

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