Neurological Evaluation

Neurological Evaluation

HISTORY
Mr. XX was initially seen in this office on 2/20/08 for neurological evaluation of his chief complaint of weakness of the 4th and 5th fingers of his right hand, as well as "loss of muscle tone" at the base of his right thumb. MRI of the cervical spine (3/3/08) demonstrated varying degrees of abnormalities from C2 through T1, particularly C4-5 and C6-7 where there is marked narrowing of the spinal canal, marked effacement of the cord, and marked narrowing of the neural foramina. - EMG/nerve conduction studies of the upper extremities (3/6/08) were abnormal, compatible with bilateral carpal tunnel syndrome and right ulnar neuropathy. There was also evidence of significant C6-7 radiculopathy on the right. Subjectively his complaints remain unchanged.
NEUROLOGICAL EXAMINATION
Mental:
• Alert and oriented to person, place, date, time and surroundings.
• Sensorium is clear and speech is intact.
• Attention and memory are normal.

Cranial:
• Ocular movements are normal.
• Fundoscopic examination is benign.
• No loss of hearing.

HeadLNeck:
• Auscultation of the carotids elicits no bruits.
• Range of motion of the neck is normal in all directions, including flexion and extension.

Motor/Neuromyscular:
• Previously noted weakness of the right upper extremity remains the same.
• There is wasting of the right hypothenar region and the 1st dorsalis interosseous.
• Phalen sign is borderline positive on the right.
• Adson sign is positive on the left.

Reflexes:
• DTR'sare symmetrical.

Sensory:
• Discrete loss of sensation in the right 4th and 5th fingers.
Station/Gait:
• There is no ataxia of gait.
RECOMMENDATIONS:
We discussed his condition and his questions were answered. At this time I am
recommending that he consider making an appointment for neurosurgical evaluation.
 
NEUROLOGIC ASSOCIATES
REASON FOR CONSULTATION
This is a 53 year old, right handed male who is seen today for neurological evaluation.
HISTORY OF PRESENT ILLNESS
Mr. XX presents with a chief complaint of weakness of his fingers of his right hand, particularly the 4th and 5th. He also reports that the 5th finger of his right hand seems to "bent" all the time. In addition, he also reports loss of muscle tone at the base of the right thumb, cold sensations involving the fingertips of his right hand, difficulty writing, holding tweezers, and unlocking things with keys. He first became aware of his presenting complaints in December 2007 following "tummy-tuck" surgery. Before the surgery he never noticed any problems and claims to have been able to do "fingertip push ups". Apparently he has lost over 100 pounds in the past 3 years, this being the reason he needed the surgery. His job entails working on computers for many hours at a time and for the past two years, or so, he has been wearing wrist bands to alleviate pressure on his wrists. He denies any significant pain or discomfort, although he admits that at some time in the past he had some discrete pain in his neck radiating to his right shoulder. However, this pain was not severe enough to cause him any significant concern.
MEDICAL HISTORY
Negative for hypertension
Negative for cardiac problems
Negative for diabetes
SURGICAL HISTQRY
Colonscopy September 2007 (normal)
Tummy tuck December 2007
CURRENT MEDICATIONS
None
MEDICATION ALLERGIES
NKDA
REVIEW OF SYSTEMS
Constitutional: Considerable weight loss with exercise and diet. No fever, or fatigue. Visual: No blurred vision, visual disturbances eye injuries or eye disease.
ENT: Voice changes. No hearing loss, tinnitus, sinus problems, or sore throat.
Cardiovascular: No chest pain, shortness of breath, palpitations, or swollen feet.
Respiratory: No chronic cough, difficulty breathing, wheezing, or asthma.
Gastrointestinal: No nausea/vomiting, diarrhea, constipation or blood in stool.
Genito-urinary: No urinary urgency, urinary frequency, or burning on urination.
Musculoskeletal: No joint pain, joint swelling, or muscle weakness.
Hematologic: No anemia, phlebitis, easy bruising, or slow to heal wounds.
Psychiatric: No confusion, nervousness, depression, hallucinations, memory loss, or insomnia.
FAMILY HISTORY
Father died at age 82 from complications of Alzheimer's.
Mother is 80 and in good health.
Two siblings, both in good health.
SOCIAL HISTORY
Single; no children.
He is self-employed.
He does not smoke cigarettes.
He does not drink alcohol.
No history of drug abuse.
NEUROLOGICAL EXAMINATION
VITAL SIGNS: Blood pressure: 173/79 Pulse: 59 Weight: 162 pounds
GENERAL OBSERVATIONS
The patient is well developed and well nourished. Arrived to the office casually, but appropriately attired. General deportment was normal. There are no obvious physical deformities.
MENTAL STATUS
• Oriented to person, place and time.
• Speech is fluent and coherent.
• There are no cognitive deficits.
• Attention span is normal.
• Recent and remote memory are intact.
CRANIAL NERVES
• I: Normal.
• II: Peripheral and central visual fields are intact. Fundoscopic examination is benign. Optic discs are normal.
There is no papilledema. There is no nystagmus. .
• III,IV, VI: Eye movements are smooth. Pupils are round and react equally to light and accommodation.
• V: Facial sensation is intact. Corneal reflexes are intact.
• VII: Facial movement is normal. There is no facial asymmetry.
• VIII: AuditorY acuity is bilaterally normal.
• IX, X: Gag reflex is present. There is no dysphagia or dysarthria.
• XI: Shoulder shrug is normal.
• XII: Tongue protrudes in the midline. Soft palate rises upward.
HEAD/NECK:
• Neck mobility is normal.
• Auscultation of the carotids elicits no bruits.
MOTOR/NEUROMUSCULAR:
• Weakness of the muscles supplied by the ulnar nerve on the right
• Weakness of adduction of the right 5th digit.
• Wasting of the right hypothenar region and 1st dorsalis interosseous.
• Borderline positive Tinnel sign bilaterally.
• Borderline positive Phalen sign bilaterally.
• Adson sign is positive on the left.
• There are no tics, tremors, spasms, or myoclonic movements noted.
CEREBELLAR
• Coordination is normal; finger to finger, finger to nose and heel to shin elicit no ataxia.
GAIT & STATION
• Gait and station are normal.
• Romberg is negative.
 
REFLEXES
• DTR'sare symmetrical.
SENSATION
• Discrete hypoesthesia in the 4th and 5th fingers on the right.
AUTONOMIC FUNCTION
• Peripheral pulses are present and equal bilaterally.
IMPRESSION
Right ulnar neuropathy.
Left thoracic outlet syndrome.
Bilateral carpal tunnel syndrome.
RECOMMENDATIONS
We discussed his condition and his questions were answered. In order to complete his evaluation I am requesting MRI studies and plain x-rays of the cervical spine, as well as EMG/nerve conduction studies of the upper extremities. He was made aware that his blood pressure was elevated; he claims to have "white coat syndrome". He brought in a diary of his blood pressure readings over the past 2 months and it is always normal. He will return to this office after the above testing is completed.
 
HISTORY
This is a 53 year old male with a chief complaint of weakness of both hands with a loss of muscle tone at the base of the right thumb. He also describes cold sensations involving the fingers of both hands.
FINDINGS:
NCS: The motor conduction velocities and latencies of the left and right median nerves, as well as the left ulnar nerve are normal. The motor conduction velocity of the right ulnar nerve is slow and the latency is prolonged across the elbow. The sensory distal latencies of the left and right median nerves, as well as the left ulnar nerve are prolonged. The sensory distal latency of the right ulnar nerve could not be obtained. The left median and ulnar, as well as the right median F wave responses are
prolonged. The right ulnar F wave response is normal.

EMG: The EMG portion of this study demonstrates increased insertional activity in the dtstrlbutior; of the right C6-7 paraspinal musculature. There is also increased insertional activity, positive spikes and signs of active denervation in the distribution of the right abductor pollicis brevis and first dorsalis interosseous. The remainder of the muscles tested are within normal limits.

IMPRESSION: Abnormal electrophysiological studies, compatible with bilateral carpal tunnel syndrome, as well as a right ulnar neuropathy. There is also evidence of right C6-7 radiculopathy. These findings should be interpreted in context of the presenting clinical picture.
 
EXAM: MRI CERVICALWITHOUT CONTRAST
INDICATION: THORACIC OUTLETSYNDROME
TECHNIQUE
An ultra-high resolution MRI scan of the cervical spine was performed on the new GEshort bore, whole body 3-Tesla Excite MRI system with a sagittal Tl-weighted fast spin echo sequence, a sagittal T2-weighted fast recovery fast spin echo sequence, and an axial T2-weighted fast recovery fast spin echo sequence with fat saturation were obtained.
FINDINGS
The brainstem and posterior fossa are unremarkable. There is no cerebellar tonsillar ectopia. The vertebral body heights, alignment, and signal are normal. C2-3: There is a small posterocentral and to the left disc protrusion resulting in mild narrowing of the anterior subarachnoid space and mild narrowing of the left neural foramina (image 15 of series 4). C3-4: There is a moderate-sized broad based posterocentral disc protrusion which does touch and mildly efface the cord and results in mild foraminal narrowing bilaterally (image 21 of series 4). C4-5: There is a large broad based posterocentral and to the right disc/osteophyte complex resulting in marked central narrowing of the spinal canal, marked effacement of the cord and marked narrowing of the right neural foramina (image 27 of series 4). C5-6: There is a large broad based posterocentral disc protrusion which touches and markedly effaces the cord and results in mild foraminal narrowing bilaterally (image 33 of series 4). C6-7: There is an extremely large posterocentral and to the right disc/osteophyte complex which marked
effaces the cord and results in marked central narrowing of the spinal canal and marked narrowing of the right neural foramina. Additionally, just caudad to this there is ischemic change and myelomalacia of the cord demonstrated (image 7 of series 3; image 39 of series 4). C7-Tl: There is a small posterocentral disc protrusion resulting in mild central narrowing of the spinal canal but no appreciable effacement of the cord or exiting nerve roots (image 45 of series 4). The cervical cord is normal in signal and morphology. The soft tissues of the neck are normal. Key images: Image 15 of series 4; image 21 of series 4; image 27 of series 4; image 33 of series 4; image 7 of series 3; image 39 of series 4p image 45 of series 4.
 
IMPRESSION
1. C2-3: There is a small posterocentral and to the left disc protrusion resulting in mild narrowing of the anterior subarachnoid space and mild narrowing of the left neural foramina.
2. C3-4: There is a moderate-sized broad based posterocentral disc protrusion which does touch and mildly efface the cord and results in mild foraminal narrowing bilaterally.
3. C4-5: There is a large broad based posterocentral and to the right disc/osteophyte complex resulting in marked central narrowing of the spinal canal, marked effacement of the 'cord and marked narrowing of the right neural foramina.
4. C5-6: There is a large broad based posterocentral disc protrusion which touches and markedly effaces the cord and results in mild foraminal narrowing bilaterally. e-
S. C6-7: There is an extremely large posterocentral and to the right disc/osteophyte complex which marked effaces the cord and results in marked central narrowing of the spinal canal and marked narrowing of the right neural foramina. Additionally, just caudad to this there is ischemic change and myelomalacia of the cord demonstrated.
6. C7-Tl: There Is a small posterocentral disc protrusion resulting in mild central narrowing of the spinal canal but no appreciable effacement of the cord or exiting nerve roots.
 
Exam Description
15208 CM XR SPINE CERVICAL 5 VIEWS
Ord Diag: THORAXIC COLLECT SYNDROME
This is a cervical spine series.
Some mild degenerative changes involving the uncovertebral joints minimal hypertrophic bone off of the lateral masses difficult oblique images there actually may be some encroachment on the neural foramen but it is difficult to tell whether its positioning are not. The lateral view shows a large anterior osteophyte off of C2 with significant disease at 5-6 and 6-7 and I think C7-Tl with large anterior and posterior osteophytes and interspace narrowing. I do not see any significant subluxation however.

IMPRESSION:
Significant degenerative changes in the lower cervical spine, correlate clinically and followup as needed either with an MRI or CT scan is needed.

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