Neurology Letters - July, 1999

July 7, 1999 Re: XXXXX
ATT: XXXXX
XXXXX
I saw XXXXX in my office and spent about an hour and 25 minutes with them. I did a complete history and physical, especially a very detailed history.

Essentially this is a 35-year old, right handed white female, whose is accompanied by her husband. He is a x-ray tech. And has his own radiology site. The patient is very cooperative, pleasant, cheerful, and somewhat pseudobulbar. (1) At the present time she gives her own history with little or no help from her husband. I am seeing her for "evaluation of her left sided body stroke".

The patient was born in XXXXX. She has always been healthy and well. She had viral meningitis (2) in 1996, at the age of 33. She states that she was treated initially with antibiotics (2) and then they were discontinued. She was treated at XXXXX at the time and presented with a headache. This did resolve completely.

She stated, as a teenager she had "migraine". She stated that it was first noted probably at the age of 16. She would have a visual event, which was a C shaped crescent visual event that was zig zaggy.(3) It would last about 20 minutes and then would go away, followed by a headache that was often on the right, sometimes on the left, and was pounding. Often times she had nausea with vomiting and sometimes had photophobia and phonophobia.(4) According to her, she would lie down and they would definitely get better after she slept, but she would have a residual headache for about 24 hours. She did have to go to the emergency room several times, but denies ever having hemiplegia, hemiparesis, numbness, or aphasia. (5) She states that in her 20’s and 30’s she would have headaches that she called migraine and they would last about 24 hours. The frequency was about once every two months. She relates that sometimes they were definitely with her period. She also states that she had headaches maybe two to three times a week that were not so severe. They were generalized. She had no nausea.
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They were sometimes quite minimal and various minor medicines, Tylenol or other medicines would help the headaches. She could have these as often as two times a week, but states she never had visual events or and other complicated features.

In May XXXX according to her, she twisted her back. She states that she twisted it by suddenly turning it to the right and she shows me with the head turning to the right. She said she did it somewhat quickly and after that period of time she had neck pain. The pain was moderately severe. It would go into her head and her neck and according to her, it probably started on May 27th. She relates when she got the onset I of the pain it was because a quick rotation twist. The pain was localized in the right and then it went into the right head. "It was not like a migraine." "It was more like a stress headache." She says that it felt more like a neck spasm. According to her, the neck pain persisted without neurological symptoms without numbness, weakness, double vision, loss of vision or other significant symptoms. She states that she saw XXXXX a chiropractor who her husband had seen. She states on the 8th however, she lost her vision on the table and she couldn’t see. It was like a black and white snowy TV. (6) It lasted for about 20 minutes. She was convinced it was in both eyes and she told XXXXX this.
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When she came to the ER she had double vision that was severe and she really couldn’t see well. She was very weak on the left side and could hardly lift her left arm. She noted that her left arm was kind of moving purposely and she couldn’t use it appropriately. At times it was "even jerking". (7) Then the arm was paralyzed and she was dysarthric. (8) According to her, she had a catheter in initially. They took it out after two days. She started to eat on the second or third day and she was transferred to XXXXX where her insurance was. She remained there for 8 days in the acute care hospital. Then was shifted to XXXXX. Rehab and XXXXX took care of her there for 10 days. She left XXXXX Rehab in a wheelchair. Her left arm was almost completely out. She could have a slight flicker of movement in her fingers. She walked with a quad cane. She still had headache and neck pain. Her bladder gave her urgency and she had pseudobulbar crying and laughing. She also had some memory difficulty. Now according to her, over one year later she is "back to near normal" mentally, but she still has some trouble piecing some things together. She has a left limp. Her left hand had difficulty and she can’t control it. She has difficulty using her left hand and arm. She splints her hand at night. She can’t button things or maneuver things. According to
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Her, she still has difficulty with her leg when walking. She has marked difficulty walking down the steps and even up the steps. At times she almost slips. She is still weak in the left foot and ankle. She drags the left ankle. She denies and numbness. She denies any loss of vision or double vision. She had some tingling on the left, but does not anymore. She does not feel that she has gotten any better in the last four to five months. She can’t tie her shoes easily. She can’t button things and she can’t zip things. She can see ok, but she has trouble running, skipping, and swimming. She has difficulty cooking because of lifting things and she has difficulty doing deskwork. She can’t use a computer. She has trouble folding clothes and cleaning. Her balance is still a problem. If anything neat requires two hands to do it she has marked difficulty with this. She is walking 10-15 minutes, but has a significant amount of difficulty doing that. She starting doing more activity, but according to her, it is a major problem for her to do things. There has been a lot of difficulty around the house in that her children run away from her and don’t mind. Once she lost her child at XXXXX. Her husband started his own business in January of XXXXX, and during that time she was the breadwinner. They now live at her mother-in-law’s house, who is 74. According to her, they are living there because they lost their home, because she was "the main supplier of income". The kids now are a problem so the mother-in-law is helping with this, especially with disciplining and keeping in touch with the kids. His business is starting to take off some and he is "starting to bring home some money".

Review of Systems: There is no diabeties, stroke or myocardial infarction. Headaches: as above. Memory loss is not present now. Smell is good. Vision is good. There is no double now, but before. There is no numbness or weakness of the face. There is no tinnitus, (9) hearing loss, or roaring dizziness. (10) Dizziness is not presented positional, intermittent or constant. Her taste is good. There is no L’Hermitte’s. (11) There is nothing that sounds like an Uhthoff’s or (12) Guthrie’s. (13) There is no dysphagia or dysarthria. (14) There is weakness on the left. There was paralysis as before. She has some numbness but not now. She has balance difficulty and walking difficulty. She has fallen some. There are no classical drop attacks. (15) She has difficulty with coordination of her left hand using her fingers. Sometimes her hand moves on it’s own or doesn’t do what she wants it to, according to her. Bladder and bowel are normal. There are no episodes of loss of consciousness or seizures.
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She states that she had tingling on her back on the left side of her thoracic area. This would come and go. It first started two years ago and it would last hours, sometimes longer. It would come on and off for one year and now it has restarted, but it is not a burning sensation. It is mainly a tingling.

Infectious Diseases: Viral meningitis as before. Allergies: None. Operations: None. Medications: Aspirin 10 grains a day.

Medical Disorders: Migraine and viral meningitis.

Family History: They have been married six and half years, have two children 4 and 3. They met in the hospital. She is a registered nurse. She went to XXXXX College. She has a maternal aunt with migraine. There is no MS, Parkinson’s, or Alzheimer’s
Social History: Any alcohol gives her a headache. It did not always trigger a classic migraine, but she would get a headache. Chocolate would give her a questionable headache and high altitude didn’t give her a headache. She drinks only socially. She smoked minimally for two years in college, but hasn’t smoked now for many years and only smoked then when she was in her late teen’s and 20’s a few cigarettes a day. Birth control pills: none for 20 years and she thinks she may have gotten some mild headaches from birth control pills.

Physical Examination: Blood pressure is 120/80 on both arms, sitting and standing. Pulse is 80 and respiratory rate is 12. She is moderately overweight. She is very pretty, pleasant young lady who has slight pseudobulbar features with one episode of crying and one episode of near crying, but is generally happy and very pleasant. She does not have a positive Sah’s sign, (16) but I cautioned her about a left frozen shoulder. She said she would exercise on it. General exam is negative. Abductor, costoclavicular, and Adson’s (17) test are normal. There is no Tinel’s or Phalen’s. (18) TMJ examination is normal. There is negative Zee’s Untenberger, and Dix-Hallpike test. (19) Head is normal without masses or bruit. Eyes and ears are normal. Nose exam, throat exam, and neck exam are all normal. Good range of motion of the neck with normal range of motion in the extension, flexion, and right to left. There is no tenderness of the neck or the Cartoids. Cartoids are 2/2 equally palpable and without bruits. Heart is normal without abnormalities, not rubs, murmurs or clicks. Lungs are clear without rales or rhonchi. (20) The extremities are normal and there is no edema. There are good pulses in the popliteal, dorsalis pedis, and posterior-tibial. Back exam is entirely normal.
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There is no evidence of spasm. There is good range of motion in all directions and Patrick sign is normal. Straight leg-raising sign is normal and there is a normal reverse straight leg-raising test. (21) There is no evidence of any abnormalities. There are no bruits over the head or neck.

NEUROLOGICAL EXAMINATION:

Mental status: Entirely normal mini mental state exam. This was done intermittently and indirectly, but she had good recall, orientation, gave a very good history. She knew all the aspects of most of the issues. The only feature was the very slight psuedobulbar aspects, crying and laughing inappropriately.

Cranial nerves: I’s intact. The fields are full. Discs are flat. EOM’s are normal. There are no nystagmus,(22) completely normal. There is no evidence of double vision. Pupils are 3/3, react. V through XII is normal. I did not find a Horner’s. She may have had a slight asymmetry of her face. Tongue AMR’s are normal. There are no other significant features. V was definitely intact to all three divisions and to motor.

There is no tremor of her head, voice or chin. She had no resting tremor (23) in the arms or legs. She had no postural tremor or kinetic tremor.(24) She had slowness of movement of her left hand, especially when doing finger to nose and AMR’s. (25) She had a wandering outstretched arm that was mainly present because of paresis and not because of cortical features. She had increased tone in her left arm and her left leg increased tone at her wrist. She had significant increased tone in her fingers. Finger tap, hand movement and RAM’S are all reduced on the left. She is about 75% slower and had marked difficulty with extension of the fingers and extension of the wrist. She has a posturing of her left arm when walking, a significant let limp, and a spasticity of her left arm. She rises from a chair with the use of only her right arm. She does have a +1 to 2 postural instability. She has loss of movements with her left arm and it is flexed. There is a negative Myerson’s sign. (26) She turns very uncertainly with balance and several times bumps into the walls.
Motor exam: Deltoid is 100/75, triceps and biceps are 100/75. Grasp is 100/60. Interossl and extension flexion of the fingers and wrist are 100/60. She has flexion posturing not only at the elbow, but also somewhat at the shoulder, at the wrist, and fingers. Iliopsoas, quads., and hamstrings are 100/90. Abductor and adductor are 100/90.
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Peroneal and extensor hallucis are 100/75 to 80. Gastrocnemius is 100/80 to 90. Extension flexion of the toes is 100/80. She has increased tone of her left lower extremity.

Sensory exam: There are some questionable vague sensory features in the left arm and leg, but pin is generally intact bilaterally. Graphesthesia, (27) finger position, and identifying coins and objects are normal on the left side. Two-point is uncertain. Right normal sensory exam.

Reflexes: No jaw or snout. Biceps, triceps, and brachioradialis are 1/1+. Knee jerks are 2/2+. Ankle jerks are 2/2+. Planters are probably 0/up and Chaddock (28) is 0/up. There is clonus on the left only. The patient walks with a left spastic hemiparentic gait, is moderately ataxic, and has postural instability. Finger to nose and AMR’s are normal on the right, but abnormal on the left. She can’t do heel-to shin well on the left. Tandem can not be done. Hop can (29) not be done on the right, but especially on the left. Romberg is probably negative.

I had them fill out a questionnaire. The patient filled out the questionnaire for memory loss and had 3 yes’s and husband had 6. The functional activities questionnaire (FAQ0 had 6 points.

Interpretation and Assessment:

1. Left spastic hemiparesis with significant hand and arm dysfunction, arm > leg with residual left leg spasticity.
2. Mild ataxia. (30)
3. Pseudobulbar state.
4. No cognitive abnormalities noted.
5. History of classical migraine clinically present before stroke.
6. History of common migraine with inducers by history.
7. History of thoracic numbness, etiology uncertain, worked up without definitive diagnosis.
8. Spontaneous vertebral dissection, vasospasm or occlusion vs. traumatic vertebral or basilar dissection.

I will discuss various aspects of the pros and cons for each one of there possibilities with you. Thank you very much.
Sincerely yours,
XXXXX