2004 Exam II Case 03

Chief Complaint:

A 40-year-old woman complains of difficulty maintaining her balance and coordinating her upper and lower extremity movements.

History of chief Complaint:

The patient is an active 40-year-female who works as a gymnastics coach and was a gymnast several years ago. She is concerned because her ability to demonstrate and assist in practices has become difficult to do over the last two weeks. Prior to this time period she was able to stand on the balance beam and demonstrate different maneuvers and techniques. At this time she can no longer maintain her balance on a beam in the static standing position. In addition, she is no longer able to guard the athletes on the high bars. Three days ago, one of the gymnasts fell and she was unable to position her arms and legs properly to help guide the fall. This past week, she has noticed subtle changes in her ability to reach and grab household objects. She also has found the need to occasionally use inanimate objects to assist her in maintaining balance while walking.

Family History:

She is married with two young daughters, both of whom are very active in gymnastics. Her husband is in good health and is also very active. The patient’s parents are both deceased. Her father died at the age of 65 from a heart attack and her mother died at the age of 72 from breast cancer.

Medical History: The patient has an unremarkable past medical history. She had a mammogram last year and there were no abnormal findings at that time.

Physical Examination: This physically fit 40-year-old female is alert, oriented and afebrile. Her skin has good color and turgor. Fundoscopic exam is normal.   S1-S2 heart sounds are present without murmur. Lungs are clear to auscultation. Abdomen is soft and non-tender without masses. Breast examination is without masses or lumps.

Neurological Examination: Mental Status: 

She is an anxious individual who is alert and oriented to person, place and time. She is articulate and has an appropriate fund of knowledge. Her speech appears slightly slower than expected with occasional slurred words; she has difficulty when attempting to pronounce the phrase Pah-Tah-Gah rapidly and needs to slow her speech for proper enunciation.

Cranial Nerves:  Visual fields are intact to confrontation. Her eyes appear to be beating side to side occasionally on forward gaze, but this finding is inconsistent. Pupils are equal and reactive to light and accommodation. She has movement of her eyes into all quadrants. Jaw-jerk, corneal and gag reflexes are intact. She has use of all facial musculature and facial sensation is intact. Normal hearing is evident to finger rub bilaterally. Her palate elevates in midline and her tongue protrudes to midline.    

Motor Exam:  Strength testing is 5/5 in all four extremities, although she has some difficulty checking her limbs to isometric testing. Reflexes are 1/4 in all four limbs. She demonstrates mild past-pointing with finger-to-nose testing in both upper extremities. Her left is worse than her right. She has difficulty with finger-thumb opposition on both sides, again left worse than right. Heel-to-shin testing reveals decreased accuracy bilaterally, however it was more evident on the left. A mild end-point intention tremor is noted with purposeful movements in the upper extremities. It is corrected on the right with stabilization of the glenohumeral joint but not the left. Rapid alternating movements are slow and symmetrical with both hands. She presents with a mild sway of the trunk in the seated position without upper extremity support. The patient has a slight veer to the left with ambulation and has a loss of balance with tandem walking.

Sensory Exam:  Vibratory sense, two-point discrimination, proprioception, pain and temperature are intact throughout her body.

Lab Studies:  Blood and CSF samples were taken for testing.

Follow-up: Follow up one-week later shows the patient to have a moderate dysarthria with speech. Reflex testing shows hyporeflexia throughout. Moderate past-pointing is present on finger-to-nose testing in both upper extremities and with heel-to-shin testing in both lower extremities. A significant end point intention tremor is noted in both upper extremities. It remains with shoulder stabilization on both sides. She is unable to sit upright without upper extremity support. She has a wide-based gait pattern and cannot walk a straight line. She has a loss of balance twice, walking in the office hallway. She cannot tandem walk without loss of balance. Serum and CSF samples are positive for Anti-Yo antibodies. Repeated mammogram reveals a small irregular mass in the upper lateral quadrant of the right breast.  

Questions

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