History and Physical — Patient 72

History

Chief Complaint: Back pain and difficulty walking.

Present Illness: This patient is a 73 year old, right-handed white female who is referred for evaluation of persistent back pain, fatigue and difficulty with ambulating. She first noted difficulty holding her head up in particular postures while dancing many years ago. This was quite noticeable to her, as she was a professional dancer. She also began to notice difficulty with flexion of her neck from a reclining position, especially when she was getting her hair shampooed at the beauty parlor.

For the last fifteen to twenty years, the patient has also experienced pain of undetermined cause. She first sought medical attention over ten years ago for difficulty walking, accompanied by pain described by the patient as "sciatica," with the right leg affected more than the left leg. She described this pain as a burning sensation originating from the hips, and radiating down to her thighs, worse in the morning. At that time, she underwent surgical intervention for a lumbar disc herniation, with relief of that particular component of her pain. Also at that time, and fluctuating over the years, she has complained of diffuse body aches, "like the flu," that have been partially relieved by massage therapy and chiropractic maneuvers. Her back pain has spread to involve her entire back and her shoulders, and she has described exacerbations of pain of "bone-breaking" severity. She has had minimal relief of pain with non-steroidal anti-inflammatory medications, and is now taking hydrocodone on a regular basis, and exercising for mobility and as prophylaxis for pain exacerbations. She has noted increasing fatigue over the years, especially during the early morning. She reports an occasional component of pain with a burning quality and ill-defined localization, extending from her trunk into her limbs.

The patient states that she fatigues easily with ambulating, as has decreased range of motion in her right hip. She describes difficulty arising from a chair and climbing stairs. She is able to walk down stairs more easily than climbing stairs; however, she remains very cautious due to fear of falling. Since five years ago, she has walked with a visible limp. Over the same period of time, she has also noted difficulty raising her arms and putting things in her cabinets. She denies any weakness of her hands. She denies dysphagia, dysarthria, diplopia, visual disturbances, numbness, paresthesia, or gastrointestinal symptoms.

The patient has undergone extensive evaluation by orthopedic surgeons and neurologists at various medical centers in the United States, including a biopsy of muscle overlying the right hip. Despite these efforts, no specific diagnosis has been made to explain her symptoms. She is now referred to one of the Teaching Clinics in the Department of Neurology, Baylor College of Medicine and The Methodist Hospital, for further evaluation. The patient repeatedly states that all she wants to know is what is wrong with her.

Past Medical History: Hypertension, scoliosis, postmenopausal symptoms. She has bilateral hearing loss, and intermittently uses hearing aids.

Past Surgical History: Lumbar laminectomy as above; recent biopsy of right hip muscle; excision of benign masses on left trunk and right axilla at age 18, without complications; dilatation and curettage.

Allergies: No known drug allergies.

Medications: Hydrocodone/acetaminophen tablets, 2 q.i.d. for pain, lisinopril 10 mg q.d., conjugated estrogen tablets 0.625 mg q.d.

Family History: The patient has a maternal aunt with muscle weakness but without associated pain. The patient's mother had progressive weakness later in life, to a degree that she had difficulty walking upright, and also had experienced considerable pain over the course of her illness. The patient has a brother who was diagnosed with scoliosis at age 76.

Review of Systems: No unusual weight loss, night sweats or fevers, and no skin rashes or lesions reported. The patient denies joint swelling, pleuritic pain, or dyspnea. She has no history of heavy alcohol intake, or of hepatitis. Her muscles do not cramp, and she denies change in urine color with exertion or with exacerbation of symptoms.

Physical Exam

General: Thin white female, appears stated age, in no acute distress, pleasant and cooperative during the examination.

Vital Signs: Blood pressure 172/78 mm Hg. Pulse 88/min, regular. Weight 118 pounds.

HEENT: No evidence of trauma. No scleral icterus. Mucous membranes are moist. Palate is normal.

Neck: Supple, no jugular venous distension, no bruits, no thyromegaly or lymphadenopathy.

Chest: Clear to auscultation bilaterally, with good air movement and diaphragmatic excursion.

Cardiovascular: Normal S1, S2, regular rate and rhythm. Normal pulses.

Abdomen: Normoactive bowel sounds, soft, non-tender. No organomegaly palpated. The abdomen was protuberant.

Extremities: No cyanosis, clubbing or edema. Full range of motion of joints, without pain or swelling. Mild scoliosis is present.

Skin: Frail appearing skin, with bruising on the left dorsal surface of the hand, but no generalized bruising and no skin rashes or other lesions.

Neurological Examination

Mental Status: Alert, oriented and conversant, appropriate thought content. Folstein Mini-Mental Status Examination score 30/30.

Speech: Fluent, without dysarthria.

Cranial Nerves:

Cranial Nerves

Findings

INot assessed.
IIPupils are round and reactive to light and accommodation, visual fields are full to confrontation.
III / IV / VIExtraocular movements are full and intact.
VFacial sensation is intact bilaterally.
VIIMild weakness of orbicularis oculi. She cannot maintain a good air seal with her lips.
VIIIShe can hear finger rubbing bilaterally, occasionally needs to ask for instructions to be repeated.
IX / XPalate is symmetrically elevated with phonation.
XISternocleidomastoid muscle strength is 4/5 bilaterally.
XIITongue protrudes midline without atrophy or spontaneous activity.

 

Motor: Normal tone, with no spasticity. She exhibits no well-defined trigger points on palpation of muscle. There is mild winging of the scapulae bilaterally, more apparent on the left than on the right. Neck flexor strength was 4+, neck extensor strength 5-. Abdominal wall musculature was lax.

Strength

Right

Left

Upper Extremities

  
Deltoid44
Biceps4-4-
Triceps4+4
Wrist Extensors44
Wrist Flexors4-4
Finger Extensors44
Finger Flexors4+4

Lower Extremities

  
Iliopsoas3+4-
Quadriceps55
Hamstrings5-5-
Ankle Dorsiflexors5-4+
Ankle Plantarflexors5-5-
Toe Extension4-4-

 

Reflexes: Tendon reflexes were 2+ in all major muscles, and symmetric.

Sensation: Decreased vibratory sense in lower extremities bilaterally. Light touch, temperature, proprioception are intact. No sensory level was detected. She has no allodynia or hyperesthesia.

Coordination: Finger to nose and heel to shin movements are performed without dysmetria or tremor.

Gait: Narrow based and steady. The patient has a tendency to swing her pelvis to maintain center of gravity over one hip while walking. She is able to stand on her heels and toes.

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