History and Physical — Patient 67

History

Chief Complaint: The patient is referred to the Neurology Service at The Methodist Hospital for evaluation of progressive lower extremity numbness.

Present Illness: She is a 31 year old right handed female from Brazil, with progressive numbness and burning dysesthesias in her feet beginning insidiously approximately 8-10 months preceding the evaluation. About five months before the evaluation she noted difficulty while dancing or wearing shoes with high heels, and felt she had poor control of her feet, with frequent turning of the feet out or down. She notes some loss of muscle mass in her calves over this time interval, without any muscle cramping or twitching. The sensory loss, which has progressively advanced to the mid-calf level, is such that she recently scalded her feet in the shower without realizing any pain. She has begun to fall frequently, and complains that her "balance is terrible."

She reports no difficulty arising from a chair or raising her arms above the shoulders. She also denies difficulties with tasks involving hand grip or wrist rotation. She describes a 4 to 5 year history of constipation, but denies urinary urgency or incontinence, sexual dysfunction, dizziness with sudden change in posture, or excessive sweating.

Past Medical History: "Underactive thyroid" not on any replacement medication, followed by an endocrinologist. "Panic attacks" associated with palpitations and relieved with benzodiazepines. No surgical procedures.

Allergies: No known drug allergies.

Medications: Clonazepam as needed for anxiety.

Social History: The patient smokes one cigarette a day, denies alcohol use. She is married, and lives in Houston.

Family History: The patient's mother died at age 42 with cardiac and renal illnesses, preceded by gait difficulty starting at age 37. Her mother's sister reportedly had similar complaints. The patient has no natural siblings through her mother, and she has no children.

Review of Systems: Other than palpitations associated with panic attacks, the patient denies cardiac symptoms. She has occasional upper respiratory infections but not of unusual frequency or severity, and denies respiratory symptoms. She denies abdominal pain or cramping, polyuria or polydipsia, or change in urine color. She denies any skin changes, rashes or lesions. She does complain of headaches for the last two years, described as bilaterally fronto-occipital, squeezing in character, with no nausea or vomiting, photophobia or phonophobia, relieved with non-steroidal anti-inflammatory drugs, and with no clear change in pattern.

Physical Exam

General: Lying comfortably in bed in no distress.

Vital Signs: Temperature 96.5 F. Pulse: 76/min (supine), 94/min (sitting for 2 min), 100/min (standing). Blood Pressure: 98/62 mmHg (supine), 102/68 mmHg (sitting for 2 min), 95/58 mmHg (standing). No symptoms elicited with change in position. Respirations 16/min.

HEENT: No bruits heard. No palpable nerves. No lymphadenopathy. No scleral or tongue discoloration.

Neck: Supple with full range of motion; no masses or bruits noted.

Chest: Clear to auscultation.

Cardiovascular: No murmur, gallop or rub heard. Normal S1 and S2. No jugular venous distention.

Abdomen: Soft without hepatosplenomegaly. Bowel sounds present.

Skin: No rashes, skin lesions, or discoloration noted on a detailed examination.

Extremities: No clubbing, cyanosis or edema.

Neurological Examination

Mental Status: Alert and conversant. Folstein Mini-Mental Status Examination score - 30/30.

Speech: Fluent with good repetition and comprehension. Labial, lingual and guttural sounds are normally pronounced. No dysphonia noted.

Cranial Nerves: Visual acuity 20/20 OU. Normal fundus and disc examination. Normal extraocular movements without nystagmus. Normal facial sensation in all three divisions of the trigeminal nerve. Intact facial muscle strength and expression. Hearing intact to finger rubbing bilaterally. Normal palatal elevation bilaterally. Intact sternocleidomastoid and trapezius strength. Midline tongue protrusion without strophy or fibrillations.

Motor: Strength of neck flexors/extensors, and upper extremity proximal and distal muscles is 5/5 on MRC grading scale. In the lower extremities, proximal muscle strength is 5/5 including hip flexors/extensors, hip adductors/abductors, knee flexors/extensors. Strength of distal muscles including plantar flexors/dorsiflexors, inversion/eversion, toe extensors/flexors is 4/5, bilaterally. No definite atrophy is noted. Tone is normal.

Reflexes: Tendon reflexes are 1/4 in upper extremities, symmetrically, and absent at knees and ankles. No pathological reflexes or upper motoneuron signs noted.

Sensation: Decreased sensation (pinprick and temperature more impaired than light touch) from feet to mid thigh. Loss of vibration sense throughout both feet. Joint position sense intact.

Cerebellar: Intact finger-nose testing and rapid alternating movements.

Gait: Slightly wide based, with slight difficulty while walking on toes. Romberg sign is negative.

Autonomic: Orthostatic pulse and blood pressure measurements as above. Increase in heart rate noted with Valsalva. Skin flare response markedly diminished in the feet.

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