2001 Exam II Case 02

CHIEF COMPLAINT:

This is a 42-year-old woman with a history of diabetes mellitus and hypertension who now presents with depression and dyskinesia. 

HISTORY OF CHIEF COMPLAINT: 

Nine months ago this happily-married mother of three began noticing that she could not focus or multi-task like she had been used to doing.  She needed to make lists to accomplish all of her errands and longed for quiet time alone.  It took extreme effort for her to complete her daily household chores.  She also noticed that she had become figety. She complained of spilling her morning coffee frequently due to uncontrolled movement.  She saw her family doctor who diagnosed her with depression and prescribed a selective serotonin reuptake inhibitor (SSRI), Zoloft. 

FAMILY HISTORY: 

Her mother is alive and doing well three months status post coronary artery bypass graft surgery.  Her father died at age 51 of liver failure due to alcohol abuse; however, he had been observed to have some bizarre adventitious motions in his limbs during the last year of his life.  She has two brothers and one sister who are all younger than she, all of which are in good health. 

MEDICAL HISTORY: 

She was diagnosed as having Type I diabetes mellitus at age 16 for which she is taking insulin.  Nine months ago, she began noticing a loss of initiative and lack of concentration.  She was easily frustrated and stubborn,  which is atypical of her prior personality.  Two months ago, she began having slight, involuntary muscle movements accompanied by some clumsiness.  She also observed that she stumbled frequently for no apparent reason when she walked. 

NEUROLOGICAL EXAM: 
MENTAL STATUS:  The patient was awake and oriented to person, place and time.  She could follow most two- and three-step commands; however, she was very irritable with her responses that were occasionally loud outbursts.  When asked to recall three items, she could only remember two out of the three.  She could perform only two rounds of serial seven's when counting backward from 100. Speech was fluent and meaningful.  Her comprehension was appropriate for her level of education. 

CRANIAL NERVES:  Her extraocular muscles were intact with visual fields testing full to confrontation.  Pupils were equal, round and reactive to light, both direct and consensual.  Both optic discs were sharp upon fundoscopic exam.  Corneal, jaw-jerk and gag reflexes were intact.  Hearing was mildly diminished in both ears, right greater than the left.  Palate and uvula elevated symmetrically.  Tongue protruded midline.  Shoulder shrug and sternocleidomastoid testing were full and equal bilaterally.

MOTOR EXAM:  Deep tendon reflexes were 2/4, bilateral and symmetric.  Strength was 5/5 in both upper and lower extremities. Finger-to-nose and heel-to-shin testing was unreliable due to the excessive movement of her extremities.  When attempting to sit at rest, an irregular, jerky motion was apparent in the proximal musculature bilaterally with a slow, writhing motion present in both wrists.  She clearly tried to hide these motions by combining them with purposeful movements.  Her gait analysis shows a loss of balance when medial knee movements are attempted. 

SENSORY EXAM:  There was loss of vibratory sensation and proprioception in a stocking/glove distribution of the hands and feet.  Pinprick sensation was intact throughout the body and face.

Questions

INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.