2002 Exam II Case 01

Chief Complaint:

A 36-year-old right-handed female who is having difficulty walking.

History of Chief Complaint:
Her complaints began with periods of dizziness 9-months ago; six months ago she noticed an instability in her gait and an abnormal clumsiness with her arms.  She comments that her clumsiness and instability are not constant; some weeks are much worse than others.  She is a primary school teacher and after her latest spell of instability she has had to take a leave of absence since she frequently looses her balance when the young children bump into her in the classroom.  Recently she has begun using a walker to assist in moving around her apartment.

Medical History:
Non-contributory
                                                                                                                       
Family History:
Sole daughter of a retired banker, lived in a major city most of her life.

Medication:
None

Physical Examination:
BP 117/78, Pulse 78, Respiratory rate 16, Afebrile

HEENT: Pupils equal and reactive.  External auditory canals clear and patent.  Tympanic membranes are intact. Neck is supple without adenopathy.  Thyroid is small without nodules.  Carotid arteries are clear without bruits.  There is no jugular vein distension.

CV:  Heart has a regular rate and rhythm without gallops or thrills.  There is a grade 1/6 systolic murmur at the left sternal border. There is good capillary refill.

Resp: Lungs are clear to auscultation and percussion.

Abd: Abdomen is soft without masses or tenderness. Bowel sounds are present without tympany.  There is no rigidity or guarding.

Neurologic Examination
Mental Status:
She is awake and oriented to person, time and place.  She is accurate in her history.  Her language and memory were appropriate and she could follow commands.

Cranial Nerves:
Her visual fields were intact to confrontation in all quadrants.  Eye movements were intact in all planes.  There was a pronounced nystagmus bilaterally that was somewhat worse to the right.  Moving her head into extreme side-bending could exacerbate the nystagmus.  Sensation on her face for touch and pin-prick were intact and her facial movements were symmetrical.  Corneal, gag and jaw-jerk reflexes were intact.  Palate elevated and tongue protruded on the midline.

Motor Systems: 
Strength and deep tendon reflexes are intact and symmetrical throughout all four extremities.  Past-pointing on finger-to-nose and heel-to-shin testing is present in all four extremities, but is somewhat worse on the right than the left.  Rapid alternating movements of her hands become asymmetric and disjoint.  Her gait is unstable; she falls to either side, but tends to fall to the right slightly more often.  She cannot attempt tandem walking due to the instability.  When seated on the examination table she sways to either side and has to hold the edge of the table with her hands to prevent falling.  Stabilizing her torso when seated did not improve the motor performance of her extremities.  She comments that her stability is worse this week and she had been much better last week.

Sensory systems:
All sensory systems were intact throughout her body.

Follow-up:
Examination in 3 months finds her instability has continued to wax and wane, but overall has worsened.  She now demonstrates a repetitive bobbing or nodding motion about her head and neck when seated without support.  She can no longer stand unsupported and requires a wheelchair.

Questions

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