Subjective
Chief Complaint: cranial neuropathies
History of Present Illness: Ms. Pasieka is a 45 y.o. woman with past medical history of IBS who was referred for evaluation of cranial neuropathies
In 2018 (age 42) she had a coronary artery dissection of unclear cause. In March of 2020 she developed headaches, fevers, fatigue and weeks later started having some facial twitching of the cheek and upper lip. She described facial spasms. Months after this her husband noticed some constant partial mild drooping of her left eye lid. This was not fatigable and did not fluctuate during the day. No symptoms noticed by the patient. No muscle weakness coming out on exercising. No difficulty with swallowing. By the fall she had some changes in her taste.
She had no weakness or numbness in the limbs. She recalls recognizing being a little unsteady over the last few years. She used to run on outdoor trails but now feels she does not have the full balance to do this. She also use to run long distances races. No new bowel or bladder issues. A week ago she developed left ankle stiffness and is wearing a fixed ankle brace today.
She recalls many years of IBS better controlled on a gluten free diet.
Not out in the woods or camping. Works in the yard occasionally.
No known infectious exposures at home but works in a lab with mice that have HSV.
Married, other family healthy. Though, father has generalized epilepsy of unclear cause with alcoholism. Mother has multiyear history of undiagnosed neurologic issues that seem to have resolved.
Review of Systems:
A complete review of systems was performed including constitutional symptoms, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, endocrine, immunologic, integumentary, hematological, and HEENT. All symptoms negative except as per HPI.
Objective
BP 114/71 (BP Location: Right arm, Patient Position: Sitting) | Pulse 56 | Temp 36.1 °C (96.9 °F) | Ht 167.6 cm (5' 6") | Wt 62.6 kg (138 lb) | BMI 22.27 kg/m²
Physical Exam:
HEENT: No lymphadenopathy, no discharge or discoloration, moist mucus membranes
Neck: no rigidity
Cardiovascular: regular rate and rhythm
Pulmonary: non-labored breathing
Musculoskeletal: no peripheral edema
Skin: no discoloration
Neurologic Exam:
The patient appeared of average build and of stated age. She was dressed appropriately, and behaved normally throughout the interview, with euthymic affect and good conversational skills. No sensory intrusions / misperceptions were noted (i.e., no delusions and/or hallucinations). She demonstrated good insight concerning the purpose for today's visit.
Mental status: awake, A&Ox4, responds to questions appropriately, follows all commands
Language: naming/comprehension/fluency intact
Cranial nerves: Visual acuity 20/20 OU, PERRLA, visual fields full to finger counting, fundoscopic exam normal, extraocular movements intact without nystagmus, alternate cover uncover normal, mild partial ptosis of the left eye, no significant worsening with sustained upgaze, facial sensation intact to light touch in V1-V3 bilaterally, face symmetric with normal strength and smile and forehead wrinkling, able to close eyes against resistance ?slight weakness of eye closure, palate elevates symmetrically, trapezius and SCM muscles strong bilaterally, tongue protrudes in midline, no dysarthria
Motor: normal tone throughout, strength on confrontation testing as follows:
Neck flexion 4/5
Neck extension 5/5
Left
Right
Deltoids
5/5
5/5
Arm Flexion
5/5
5/5
Arm Extension
5/5
5/5
Wrist flexors
5/5
5/5
Wrist extensors
5/5
5/5
Finger flexors
5/5
5/5
Finger extensors
5/5
5/5
Hip flexion
5/5
5/5
Leg flexion
5/5
5/5
Leg extension
5/5
5/5
Dorsiflexion
5/5
Plantarflexion
5/5
Fixed leg brace on the right but when removed the ankle is stiff with limited ROM and mild swelling, no erythema
Sensory: Temp/touch: intact
Vibration: mild loss at the both ankles (16s), moderate loss at the knees (10s) trace loss at the thumbs
Romberg negative
Reflexes:
Left
Right
Brachioradialis
2+
2+
Biceps
2+
2+
Triceps
2+
2+
Patellar
2+
2+
Ankle
2+
2+
Plantar response
Delayed ankle relaxation
Coordination: Finger to nose intact,
Slowed finger tapping and hand closing
Gait: narrow-based with normal stride and arm swing; able to tandem without difficulty
Assessment/Plan
Ms. Pasieka is a 45 y.o. woman with past medical history of spontaneous coronary artery dissection, who has had a recent decline with some mild unsteadiness, a constant mild left eye partial ptosis without diplopia, hemifacial spasm, and changes in taste. No signs of systemic arteriopathy or CNS involvement when evaluated
On neurologic exam she does have a mild left eye partial ptosis without signs of ophthalmoplegia or pupil involvement. Other cranial nerves including CN VII were intact. May have some slight slowing of coordination that could be normal but possibly related. She had a mild sensory loss to vibration with a variable pattern. And a mildly swollen, stiff right ankle.
We discussed the available recent lab results, which were unremarkable. They asked about next steps before they plan to relocate out of state in June. The symptoms are not specific, though do seem like a slight decline with additive issues. The diagnosis is not clear at this point but we discussed pursing an MRI as the next step. Would be helpful to have a better understanding of her mother's undiagnosed neurologic issues.
. MRI brain
I spent 60 minutes today with Tracy Jo Pasieka, documenting and reviewing her care, with more than 50% of the time spent discussing many of the issues relating to the diagnosis, symptoms, and management of ptosis and unsteadiness. Discussion and decision making was of high complexity due to the patient's high-risk condition, multiple co-morbidities, neuropsychological co-morbidities, and/or multiple sites of involved disability.
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