Document info

Result type: Neurology Consultation

Result date: Sep 21, 2021, 01:23 a.m.
Result status: modified
Performed by: Monique Hedmann
Verified by: Monique Hedmann
Modified by: Edward Chang

Consult Note
ANNETTE
Patient: DOB: Mar 25, 1960
GOEPPNER

Reason for Consultation Problem List/Past Medical History

Lower extremity weakness, MRI findings Ongoing
Depression
History of Present Illness
Hypertension
Annette Goeppner is a 61F w/ PMH of pre-DM, depression, HTN, and
Imbalance problem
traumatic head injury 2/2021 who presents in the ED from FM clinic with
Obesity
progressive LE weakness and falls.
Prediabetes
Earlier this year (either January or February 2021), pt hit head on concrete Well adult check
w/ LOC Historical
Since then has been experiencing dizziness and imbalance, as if "walking on No qualifying data
a boat" Medications
Weakness is concentrated from knees down to feet bilaterally, strength Inpatient / In-Clinic
elsewhere is normal CeleXA, 20 mg= 1 tabs, Oral, QDAY
Says that the 3 smallest toes on rt foot and lt great toe often "curl up" while lisinopril, 20 mg= 1 tabs, Oral, BID
she's walking, causing falls Home
Began using a cane and then a FWW in order to ambulate, very helpful - CeleXA 20 mg oral tablet, 20 mg= 1
also has wheelchair tabs, Oral, QDAY, 2 refills
Feels that her LE weakness has gotten progressively worse in the past few ergocalciferol 50,000 intl units (1.25
weeks - 1 month mg) oral capsule, 50000 IntlUnits=
Has had at least 8 falls since sx onset, most recently on 9/12/21 during a trip 1 caps, Oral, QWEEK-SUN
Legs "gave out on her" - took 4 hours to drag herself across the floor to her lisinopril 20 mg oral tablet, 20 mg= 1
wheelchair tabs, Oral, BID, 11 refills
Allergies
Review of Systems Doxycycline Hyclate (Hives, Rash)
Constitutional: Denies weight loss, fever, chills
HEENT: Denies changes in vision and hearing Social History
CV: Denies chest pain and palpitations Alcohol
Resp: Denies SOB, cough, wheezing Current, Wine, 1-2 times per week
GI: Denies abdominal pain, nausea, vomiting, constipation, Home/Environment
melena, hematochezia Lives with Mother. Alcohol abuse in
GU: Denies dysuria, hematuria, urinary frequency, incontinence household: No. Substance abuse in
MSK: Denies myalgia and joint pain household: No. Smoker in household:
Neuro: Endorses BLE weakness in lower legs and feet No. Injuries/Abuse/Neglect in
Psych: Denies recent changes in mood household: No. Risks in environment:
Pets/Animal exposure.
Physical Exam
Sexual
Vitals & Measurements Identifies as female Gender Identity:.
T: 36.1 °C (Oral) HR: 74(Monitored) RR: 14 BP: 137/81 SpO2: 99% Straight or heterosexual Sexual
HT: 157 cm WT: 95.4 kg Orientation:.
Pain Present: No (09/21/21 00:42:00) Substance Abuse
Gen: NAD, comfortable appearing Never
CV: RRR, no m/g/c Tobacco
Resp: CTAB no w/r/c Never (less than 100 in lifetime)
Ext: non-pitting edema present b/l, hyperpigmentation of lower legs Tobacco Use:.
Family History
NEURO: Diabetes mellitus: Father.
Mental Status Hypertension: Mother.
- AOx4 Stroke: Father.
- intact speech and language, no dysarthria
- cooperative

Cranial Nerves
- grossly normal visual field testing
- normal eye movement range
- normal facial sensation to light touch
- face symmetric, normal facial muscle movement, eyebrow raise intact
- normal hearing to finger rub
- normal speech, no dysarthria, no uvular deviation
- normal neck ROM, trapezius intact/symmetric
- normal tongue movement

Motor
- normal tone throughout
- normal bulk throughout
- no pronator drift
- no spasticity noted
- no tremor/other involuntary movement
- no bradykinesia/dyskinesia

Strength
Shoulder ABduction R 5/5 L 5/5
Shoulder ADduction R 5/5 L 5/5
Elbow flexion R 5/5 L 5/5
Elbow extension R 5/5 L 5/5
Wrist flexion R 5/5 L 5/5
Wrist extension R 5/5 L 5/5

Hip flexion R 5/5 L 5/5

Hip extension R 5/5 L 5/5
Knee flexion R 5/5 L 5/5
Knee extension R 5/5 L 5/5
Plantarflexion R 3/5 L 3/5
Dorsiflexion R 1/5 L 1/5

Coordination
- normal B/l finger-to-nose
- normal B/l rapid alternating movements

Sensory
- intact to light touch and symmetric throughout dermatomes
Gait and Station
- deferred (Per FM clinic note: - inability to walk, abnormal Romberg, swaying
+)

Labs

WBC: 5.4 K/cumm (09/20/21 16:11:00)

RBC: 4.38 M/cumm (09/20/21 16:11:00)
Hgb: 13.8 g/dL (09/20/21 16:11:00)
Hct: 41.3 % (09/20/21 16:11:00)
MCV: 94.2 fL (09/20/21 16:11:00)
MCH: 31.5 pg (09/20/21 16:11:00)
MCHC: 33.4 g/dL (09/20/21 16:11:00)
Platelet: 370 K/cumm High (09/20/21 16:11:00)
RDW: 14 % (09/20/21 16:11:00)
MPV: 6.8 fL Low (09/20/21 16:11:00)

AGAP: 7 (09/20/21 16:11:00)

Albumin Lvl: 3.9 g/dL (09/20/21 16:11:00)
Alk Phos: 64 U/L (09/20/21 16:11:00)
ALT: 24 U/L (09/20/21 16:11:00)
AST: 23 U/L (09/20/21 16:11:00)
Bili Direct: 0.1 mg/dL (09/20/21 16:11:00)
Bili Total: 0.8 mg/dL (09/20/21 16:11:00)
BUN: 16 mg/dL (09/20/21 16:11:00)
Calcium Lvl: 9.5 mg/dL (09/20/21 16:11:00)
Chloride Lvl: 104 mmol/L (09/20/21 16:11:00)
CO2 Lvl: 28 mmol/L (09/20/21 16:11:00)
Creatinine Lvl: 0.48 mg/dL (09/20/21 16:11:00)
eGFR African American: 123 mL/min/1.73 m2 (09/20/21 16:11:00)
eGFR Non-African American: 106 mL/min/1.73 m2 (09/20/21 16:11:00)
Glucose Lvl: 102 mg/dL (09/20/21 16:11:00)
Hgb A1c: 5.7 % High (06/15/21 12:04:00)
Magnesium: 2.2 mg/dL (09/20/21 16:11:00)
Phosphorus: 3.9 mg/dL (09/20/21 16:11:00)
Potassium Lvl: 4.7 mmol/L (09/20/21 16:11:00)
Protein Total: 6.9 g/dL (09/20/21 16:11:00)
Sodium Lvl: 139 mmol/L (09/20/21 16:11:00)
Vitamin D 25 OH: 18 ng/mL Low (08/11/21 10:02:00)

Imaging/Studies

(08/24/2021 14:42 PDT MRI Brain w/o Contrast)

(08/24/2021 14:43 PDT MRI IAC w/ + w/o Contrast)

IMPRESSION:
1. No acute intracranial hemorrhage, extra-axial fluid
collection, hydrocephalus or acute infarction. No enhancing
mass in the internal auditory canals or cerebral pontine angles.

2. Crowding at the foramen magnum, 5 mm caudal descent of the

cerebellar tonsils, and apparent slight brainstem slumping.
These findings are non-specific but can be seen in the setting
of intracranial hypotension; correlate with symptomatology.

3. Nonspecific T2 FLAIR signal hyperintensities predominantly

in the bifrontal subcortical white matter. Although
non-specific the distribution suggests changes related to
migraine headaches. Chronic microvascular ischemic change could
have a similar appearance.
 [1]
Assessment/Plan
Annette Goeppner is a 61F w/ PMH of pre-DM, depression, HTN, and
traumatic head injury 2/2021 who presents in the ED from FM clinic with
progressive BLE weakness and falls. Pt will be admitted to Family Medicine
IPS for management. Neurology was consulted for BLE weakness and
unique non-specific MRI findings.

Recommendations:
- MRI lumbar spine w + w/o contrast
- Consider nerve conduction studies if indicated based on MRI results
- Heavy metal screening labs: lead, arsenic, mercury
- Peripheral neuropathy labs: B12, (homocysteine, MMA), TSH, SPEP/UPEP,
A1c
- PT eval

Discussed with senior resident Dr. Tamrazian.

To be discussed with attending Dr. Chang.

Monique Hedmann MD MPH

PGY-2, Family Medicine
*1107

[1] MRI IAC w/ + w/o Contrast; Ceglar, Sarah Russell 08/24/2021 14:43 PDT

Addendum by Maki, Niki Zahra on September 21, 2021 18:17:47 PDT

The pt was visited in the morning and again during neurology rounds. She denies any urinary or bowel
incontinence,some times has urinary accidents due to not being able to ambulate to the bathroom, but she can feel
her urine and BM.
On exam CN II-XII intact. Motor and sensory exam on bilateral UEs WNL. On lower extremity , she has limited range
of motion on active and passive dorsiflexion of BL feet. No spasticity was noted on other muscle groups. Muscle bulk
is normal throughout. Sensation was intact on BL LEs. DTR 2+ symmetrical on upper extremities, 1+ bilateral patellar
and absent BL Achillis. No Hoffman, no Babinski

Hip flexion R 4-/5 L 5/5

Hip extension R 5/5 L 5/5
Knee flexion R 4/5 L 4/5
Knee extension R 5/5 L 5/5
Plantarflexion R 4/5 L 4/5
Dorsiflexion R 3/5 L 3/5
Toe extension R3/5, L 3/5 except for left big toe which is 0/5
ankle eversion and inversion 4/5 BL

#Progressive BL lower extremity weakness, without sensory deficits

Recommendations:
-Please obtain CK, ESR , CRP, to rule out myopathies
-MRI lumbar spine to r/o any space occupying lesions or other anatomical problems
-EMG- NCs to rule out possible CIDP

Attestation: The pt was discussed with the attending physician Dr. Chang.

Niki Maki, MD
Neurology PGY2
Addendum by Chang, Edward on September 22, 2021 09:13:45 PDT

ATTENDING ADDEDNUM:
Patient and plan discussed with the Neurology Consult team.
61F who was referred from clinic to the ED for approximately 6 months of progressive leg weakness. On exam, her
main symptoms were inability to dorsiflex either foot as well as limitation on passive range of motion. Patient noted
recent incontinence, but this was due to inability to get to the bathroom on time due to difficulty walking. Reflexes not
obtainable at ankles due to limited PROM. Needs MRI L-spine to determine whether there is a structural reason for
her bilateral foot drop; consider EMG/NCS if MRI unrevealing.