351853846 WGH
8921553
92855
715722
3/24/1997 12:00:00 AM
GAIT DISORDER .
Unsigned
DIS
Report Status :
Unsigned
DISCHARGE SUMMARY NAME :
PREHEPRIOR , NIENEMILEISELE
UNIT NUMBER :
372-41-54
ADMISSION DATE :
03/24/97
DISCHARGE DATE :
03/28/97
PRINCIPAL DIAGNOSIS :
Gait disorder .
HISTORY OF PRESENT ILLNESS :
The patient is a 31-year-old right-handed female with right-sided greater than left-sided weakness and difficulty walking for several days .
She was in her usual state of health until 3/20/97 when she experienced the fairly sudden onset of predominantly right-sided arm and leg weakness and ataxia .
She was standing and walking with her friend , who " had to catch her from falling down " as she toppled towards the right .
She evidently recovered from the episode after a number of minutes .
The following day , she remained in bed through essentially all of the day due to malaise with no specific deficits being noted .
In the subsequent two days , she had several small spells of " imbalance " , particularly towards the right , and other symptoms included diffuse and mainly frontal headaches and mild neck soreness .
There was no diplopia , visual loss , speech abnormality or sensory change in her history .
She was initially evaluated at an outside hospital emergency room , and then transferred to Well General Hospital .
PAST MEDICAL HISTORY :
Is notable for depression , and she has been followed regularly by Dr. Freiermchird of Nash Health for several months with pharmacologic treatment , which is apparently working well .
Her Doxepin has recently been increased .
She is status post appendectomy and otherwise has no remarkable past medical history .
ALLERGIES :
Quinine gives her a rash .
MEDICATIONS ON ADMISSION :
The only medications she is on are Paxil 30 mg p.o. q.day , Doxepin 25 mg p.o. q.day , and Klonopin 2 mg p.o. q.h.s.
SOCIAL HISTORY :
She is currently unemployed , but until recently , she was employed at a bank .
She was born and raised in Atonlaremont Rockpo .
There is a history of childhood abuse .
She does not drink .
She is a former tobacco user and takes no illicit drugs .
PHYSICAL EXAMINATION :
She was pleasant , in no acute distress ; blood pressure 130/60 ; heart rate 66 ; respirations 18 ; temperature 98 .
Her thyroid was within normal limits .
There were no carotid or cervical bruits .
She had a normal S1 and S2 and regular rate and rhythm with no murmurs .
Her lungs were clear to auscultation bilaterally .
Her abdomen was benign .
Her extremities were without clubbing , cyanosis , edema , or rash ; there were some older hematomas in the bilaterally shins .
Mental status - her speech was fluent without errors .
Her affect was slightly inappropriate at times ; for example , singing or humming along while performing some of the motor tasks and giving the impression of indifference to the deficits that were demonstrated on the examination .
Her memory was fully intact for short-term recollection of three out of three objects at five minutes with excellent naming , repetition , proverb interpretation , and ability to follow commands .
Visual fields were full to confrontation .
Her left pupil was 7 mm reacting to 5 mm .
Her right pupil was 5.5 mm reacting to 4 mm .
Her extraocular movements were intact for horizontal and vertical pursuits .
There was no nystagmus and no ptosis .
Her saccades were normal .
Facial strength and sensation were full and symmetric .
Her tongue , uvula and palate were midline .
Shoulder shrug was 5/5 power .
Motor examination revealed 5/5 power in all groups in the proximal and distal upper and lower extremities .
There was no drift .
There was normal bulk and tone .
She had slightly slow fine finger motility approximately equal bilaterally , although this was extremely difficult to reproduce .
Sensory - intact light touch , temperature , and vibration overall .
Reflexes were 2+ throughout in the upper and lower extremities , and toes were downgoing .
There was no jaw jerk and no Hoffman 's sign .
Coordination - toe tap was slow bilaterally , although difficult to reproduce , and at best , was essentially within normal limits .
On standing , she tended to fall to the front , back or sides without trying to stop her fall initially , and extensive gait testing was deferred due to concerns for safety .
Her heel-to-shin and finger-to-nose testing was fully intact bilaterally without ataxia or tremor .
LABORATORY DATA :
Were unremarkable with normal electrolytes and complete blood count parameters .
Her erythrocyte sedimentation rate was 12 .
Her coagulation parameters were normal .
Head CT scan without contrast showed normal brain parenchyma and no intracranial process .
HOSPITAL COURSE AND TREATMENT :
The patient was admitted for her gait disorder with other notable findings on examination including anisocoria , which , by the patient 's report , had been noted several months earlier .
A magnetic resonance imaging and magnetic resonance angiogram study was obtained , which showed no clear evidence of arterial dissections or infarction or other pathologic processes .
She had been placed on heparin initially , but this was discontinued after the magnetic resonance imaging results were obtained .
Posterior transcranial Doppler studies showed normal studies of both vertebral arteries , and carotid non-invasive studies showed normal right and left carotid bifurcations .
On the second hospital day , her gait continued to be markedly unstable , although with no consistent pattern in terms of weakness or directionality of falling , and she continued to have no reproducible upper extremity or lower extremity ataxia or dysmetria .
She was seen by the Psychiatry Service .
She was not felt to be acutely suicidal or otherwise in need of acute psychiatric treatment .
The psychiatrist also noted the indifference the patient evinced regarding her own symptomatology .
The patient was evaluated in one of the neurology conferences for several hours , and during this time , showed significant improvement while receiving gait training as well as evaluation ; in particular , she became more stable with counter-balancing methods .
This trend of improvement continued , and she was discharged in stable condition .
She will follow up with her psychiatrist , Dr. Freiermchird ( Sone Memorial Hospital ) on a regular basis , and she can follow up with the Neurology Service on a p.r.n. basis if needed .
She will continue on her previous outpatient medical regimen .
NIREGE MEMORY , M.D.
TR :
bzo
DD :
03/29/97
TD :
03/31/97 12:36 P
cc :
NYRI A MEMORY , M.D.
ASHELLRIETTE NESSASU THREATSVOT , M.D.
EJEAN NADARC FREIERMCHIRD , M.D.