Strength as Reporter
All the elements of a good presentation are given and the exam is reliable.
HPI: This is a first time Neurology Clinic visit for this 38-year-old female referred for evaluation of ataxia. The patient is accompanied by her mother who gives part of the history.
Onset of difficulty was two to three years ago. She describes being off balance, and has trouble walking down hills because her legs feel like "Jell-O." Otherwise, strength is not a problem in her legs. No sensory abnormalities in the legs. She does not feel there are any problems in her arms in terms of strength or coordination. Her left arm will fall asleep at night, and her elbow hurts at times. Occasionally her eyes dart back and forth for short periods. She is nearsighted and has worn glasses for a few years. No bowel and bladder incontinence, but she does have frequent urination. Onset of all these symptoms has been insidious. At no time have there been sensory, motor or visual changes that have come and gone over days to months.
Relevant past history includes the following. She used heavy daily alcohol, and remained somewhat drunk for four years, but that ended four years ago when she got more into cocaine. Two years ago she moved in with her mother to try and beat her drug habits. There is no history of IV drug use. Depression has been a life long issue. She has had many closed head injuries. Only once did she have loss of consciousness. During the most severe head injury, she noticed her left pupil was dilated for one month. She was born full term but blue with a nuchal cord. There were learning disabilities as a child treated with Ritalin for a period.
REVIEW OF SYSTEMS: Positive for fatigue, memory trouble, trouble concentrating, past headaches, trouble sleeping, depression, change in sweating, blurry vision, orthostatic dizziness, tinnitus, trouble breathing through her nose, palpitations, ankle swelling, daily cough, shortness of breath, frequent stomach pain, joint pain, chronic low back pain, and night sweats. She has had two episodes of tunnel vision, chest pressure, head weirdness that got better when she laid down. All other review of systems are negative according to the health history form reviewed today.
SOCIAL HISTORY: She smokes a pack per day, and has done so for 20 years. Other drug habits are described above.
PAST MEDICAL HISTORY: (complete in write-up)
FAMILY HISTORY: Negative for cerebellar or neuropathy syndrome.
GENERAL: This is an alert female, who is quite emotional today.
VITAL SIGNS: Height 6'0", blood pressure 122/64, heart rate 64, weight 166.7 pounds.
Carotid auscultation is negative. Memory, language, and fund of knowledge all seem normal.
EYES: Pupils were slightly anisocoric, left greater than right, but not much, and no change from light to dark. Extraocular movements intact without nystagmus. Funduscopic examination was difficult, but nothing specific was seen. FACE: Normal motor and sensory examination. MOUTH: Oropharynx benign.
EXTREMITIES: Strength was 5/5 in all muscle groups with the ability to walk on her toes and heels, and get out of a low chair without using her arms. She has high arches. No atrophy is seen. Reflexes 2/4 at the biceps, 2/4 at the wrist, 1/4 at the knees, 1/4 at the ankles, both sides equal. Toes are downgoing bilaterally. Sensory examination shows intact vibration, but proprioception was maybe mildly reduced at the toes. Finger-to-nose and heel-to-shin were both moderately dysmetric. She does have truncal titubation both when sitting and walking. Her gait looked a little spastic, and mildly wide based. There was no increased tone to direct testing in her legs.
LAB DATA / RADIOGRAPHS: Chem panel and TSH normal. No films.
ASSESSMENT: This 38 year-old female has gradually progressive coordination difficulty.