History and Physical — Patient 7

History

Patient #7 is a 48 year old female who presented to the Department of Neurology for evaluation and second opinion. She first developed symptoms two and one-half years ago when she began to feel unsteady when she was walking, especially when descending stairs. Her instability continued to progress and she would occasionally fall. She also lost interest in her hobbies, quit her job, and appeared to smile and talk less. Shortly thereafter, she began to experience vision problems; specifically she had difficulty focusing on objects close to her and had difficulty reading and watching TV. Her husband complained that she would not make direct eye contact with him and he described her as looking "scared" all the time.

Past Medical History: Right upper extremity weakness secondary to a birth injury.

Past Surgical History: Left corneal transplant secondary to surgery, ruptured ovarian cyst, and hysterectomy.

Medications: Eldepryl and premarin.

Family History: Negative for neurologic disease.

Social History: No history of tobacco use, alcohol, or IV drugs.

Review of Systems: Significant for dysphagia, liquids more than solids. She had urinary frequency with some incontinence, but no bowel incontinence.

Physical Exam

Vital signs were normal. Blood pressure: 104/60 sitting with a heart rate of 88, 100/58 standing with a heart rate of 92. General examination was unremarkable.

Neurological Examination

Funduscopic Examination

Funduscopic Examination: OD and OS, respectively

Mental Status: Alert, awake, and oriented times three. Mini-mental status examination was 28/30 (two points deducted for serial 7's). Speech was slow, but fluent with repetition, comprehension, and naming intact. No difficulty with labial, lingual, or guttural sounds.

Cranial Nerves: Pupils) Left pupil nonreactive, status post surgery.

Eye Movements

Eye Movements: Doll's head maneuver.

Extraocular Movements

Extraocular Movements: The patient is asked to look in the various positions of gaze, as indicated by the arrows.

Motor: Increased tone in all four extremities.

Strength

Right

Left

Upper Extremities

  
Deltoid4-5
Biceps3+4-
Triceps3-4-
Wrist Extensors34-
Wrist Flexors34-
Finger Extensors34-
Finger Flexors34-

Lower Extremities

  
Iliopsoas4+4+
Knee Extensors4+4+
Knee Flexors4+4+
Ankle Extensors4+4+
Ankle Flexors4+4+

 

Reflexes:

Reflexes

Right

Left

Biceps1+2+
Brachioradialis1+2+
Patellar2+3+
Ankle jerk2+2+
Jaw jerkAbsent 
HoffmanAbsent 
GlabellarAbsent 
SnoutAbsent 
PalmomentalPresent bilaterally 

 

Sensation: Intact to pinprick, temperature, vibration, and proprioception bilaterally.

Cerebellar: Normal finger to nose, heel to shin. No loss of check or titubation. No tremor.

Gait: Steady, slow, slightly stiff, with decreased arm swing. Normal toe walking, but difficulty with heel and tandem walking.

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