DISCHARGE SUMMARY BAYLOR COLLEGE OF MEDICINE
Name: Peggy K. Williams One Baylor Plaza
Hospital Number: xxxxxx Houston, Texas 77030-3498
Date of Admission: 03/08/2004 Stanley H. Appel
Date of Discharge: 03/10/2004 Professor and Chairman
Discharge Diagnosis: ALS TEL:(713) 798-4073
Procedures in Hospital
2. Bedside force vital capacity
3. Neuropsychological testing
HISTORY OF THE PRESENT ILLNESS:
Ms. Williams is a 58-year-old lady presenting with progressive spasticity and weakness in her legs as well as multiple falls. About six years ago she started having cramps in her feet and charley horses in her legs which have progressively worsened since then and now bothers her constantly even waking her from sleep. About eight months ago she was out in her yard and just fell for no reason. Since then, she has started falling more frequently, about two to three times per week. She has trouble walking and notes that her legs will either lock up or just crumble underneath her. After she falls, she is too weak to get up. She first noticed weakness in her right leg about five months ago. This has also gotten worse and now the left leg is also weak. About four months ago, Ms. Williams noticed that her right leg would start jerking when she was sitting down. This would only happen every now and then, but now both legs will jerk and it occurs every day. Over the past two to three months, she has just started to have urinary and fecal incontinence. The urinary incontinence is described as leaking not long after she has gone to the bathroom and feels like she had completely emptied her bladder. This occurs every day. Her fecal incontinence is described as a sudden urge to defecate and then not being able to hold it until she gets to the bathroom. This only happens about twice a month. Ms. Williams also reports having a bad headache each morning for the past few months. She notes her short-term memory is not as good as it was six months ago.
Medical: Breast Cancer in 1971; 3 spontaneous abortions and one stillbirth. Surgical: Appendectomy; radical mastectomy in 1971; hystorectomy in 1986; partial left mastectomy and breast implants in 1976. Allergies: Codeine causes a severe headache. Medications: Vioxx 25 mg p.o.q.d.; Quinine 325 mg p.o.q.h.s. Family History: Mother is alive at 81 years old and has had multiple strokes and COPD. Father died at age 73 of emphysema and myocardial infarction. A sister has hypertension. There is no neurological disease in the family. Social History: She smokes 1 -pack/day for 29 years. She seldom uses alcohol. She denies recreational drug use. She is married and has one child and two grandchildren. She works as a secretary. Review of Systems: Notable for headaches and incontinence as noted in HPI. Negative for weight gain or loss, fatigue, fever, chills, sore throat, chest pain, palpitations, shortness of breath, cough, nausea, vomiting, diarrhea, dysuria, hematuria, heat or cold intolerance, excessive thirst, excessive bleeding or bruising.
Physical Examination: Vital Signs: T = 97.3. P = 71. RR = 16. BP = 128/70.General Appearance: The patient is sitting comfortably in the bed and is in no acute distress.
HEENT: Normocephalic, atraumatic. Sclera anicteric. Oropharynx clear. Neck: Supple. No carotid bruits. Chest/Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm without murmurs, rubs or gallops. Abdomen: Soft, nontender, and nondistended. Positive bowel sounds. Extremities: No clubbing, cyanosis or edema. Skin: No rashes or lesions.
Neuroexamination: Mental Status: She scored 30/30 on the Mini-Mental Status Examination. Speech: Fluent without repetition or comprehension errors. Labial, lingual and guttural sounds are intact.
I. - Not tested.
II. - Pupils are equal, round and reactive to light and accomodation. Visual fields are full to confrontation bilaterally. Visual acuity is intact.
III., IV., VI. - There is a full range of motion of extraocular movements without nystagmus.
V. - Pinprick and light touch are intact in VI - V3 bilaterrally. Corneal reflex is present bilaterally. There is good bulk and strength of masseter, pterygoid and temporalis muscles bilaterally.
VII. - Orbicularis oris and orbicularis oculi strength 4/5 bilaterally.
VIII. - Hearing is intact bilaterally.
IX., X. - Symmetric elevation of the palate. Gag reflex is present and equal bilaterally.
XI. - Sternocleidomastoid strength 4+/5
Trapezius strength 5/5.
XII. - Midline tongue protrusion without atrophy or fibrillations.
Neck flexors 3+/5
Deltoids 4-/5 bilaterally
Biceps 4+/5 bilaterally
Triceps 5-/5 right 4+/5 left
Wrist extensors 4+/5 bilaterally
Wrist flexors 4+/5 right 4/5 left
Finger extensors 4+/5 right 4/5 left
Finger flexors 5/5 bilaterally
Hip flexors 4-/5 bilaterally
Knee extensors 4-/5 right 4+/5 left
Knee flexors 4/5 bilaterally
Ankle dorsiflexors 4/5 right 4+/5 left
Plantar flexors 4+/5 bilaterally
Toe extensors 4/5 bilaterally
Toe flexors 4/5 right 4+/5 left
Muscle tone is normal in the upper extremities and increased in the lower extremities with clonus of right lower extremity.
Triceps 3+ right 2+ left
Biceps 3+ right 2+ left
Brachioradialis, patellar 3 bilaterally
Ankle jerks 4 right 3 left
Crossed abductor responses are positive bilaterally. Plantar responses are downgoing. Hoffmann's, jaw jerk, and snout are positive. Glabellar and palmomental are negative.
Sensory Examination: Pinprick is slightly decreased in the right leg below the shin down. Vibration is slightly increased in toes on the right. Temperature and propriception are normal. Romberg is negative.
Coordination: Finger-to-nose shows terminal oscillations. Heel-to-shin is slow. There is no truncal ataxia or titubation.Gait: Spastic but normal base. Unable to walk on heels or toes.
HOSPITAL COURSE: The patient was admitted to the Jones 9 Outpatient Unit for evaluation of her progressive spasticity and muscle weakness. On day one, she underwent bedside forced vital capacity and EMG. On day two, the patient underwent neuropsychological testing. During the hospital course, she developed no headache and remained basically unchanged.Laboratory Studies: Sodium 145, potassium 3.6, chloride 108, bicarbonate 27, BUN 12, creatinine 1.0, glucose 87, calcium 9.2, WBC 4.92, hemoglobin 13.8, hematocrit 42.0, platelet count 241,000, MCV 92.1, PT 13.1, PTT 28.7, INR 0.9, AST 19, ALT 9, alkaline phosphatase 104, protein 7.0, albumin 4.6, total bilirubin 0.3, direct bilirubin 0.1, CPK 93, ESR 16, RPR nonreactive, TSH 2.73, T3 RU 81, T4 7.5.
Pending studies: ANA, HTLV and rheumatoid factor.
Urinalysis - negative protein, glucose, nitrites; WBC 0, RBC 1; moderate bacteria.
Special Studies: Bedside Forced Vital Capacity: 3.36 liters (104% of predicted).EMG/NCV: Abnormal study. Motor latencies and velocities are normal, but sural sensory responses are absent suggesting sensory neuropathy. In addition, there is evidence of denervation in tongue, thoracic paraspinous, arm, and leg muscles. This study suggests widespread motor neuron disease and sensory neuropathy.
Neuropsychological Testing: Please see separate report.
Outside Studies: Brain MRI is unremarkable.MRI of Cervical Spine revealed mild disk bulge at C5-6 and circumferential bulge at C6-7, but no cord compression.MRI of Thoracic Spine is unremarkable.
Consultations: ALS Team: Occupational Therapy; Physical Therapy; Speech Therapy; Dietary; Social Services; Dr Cross, Pulmonary Medicine; Neuropsychology.
SUMMARY: Ms. Williams is admitted for evaluation of her progressive spasticity and weakness. Physical examination showed spasticity and increased reflexes. Also, there was weakness. EMG showed findings suggestive of motor neuron disease and sensory neuropathy. Although she has urinary and bowel incontinence, the perianal sensation is good. We believe that Ms. Williams has ALS. She was seen by the ALS Team and all questions were answered to her satisfaction. She will be followed in the MDA/ALS Clinic on Friday in three to four months. During her hospital course, baclofen was started and she noted her spasticity had improved.
- Rilutek 50 mg p.o.q.12 hours.
- Baclofen 10 mg p.o.t.i.d.
- Vitamin C 1,000 mg p.o.t.i.d.
- Vitamin E 1,000 IU p.o.t.i.d.
- Beta Carotene 25,000 IU p.o.b.i.d.
- Melatonin 3 mg p.o. 20 minutes before bedtime
- Coenzyme Q-10 100 mg p..b.i.d.
Stanley H, Appel, M.D./Kenkich Nozaki, M.D.
Professor and Chairman
cc: Benjamin Nguyen, M.D.
Ms. Williams returns today for a follow-up after returning from Houston. She has a diagnosis of ALS.
Neurological exam is unchanged compared to before. She still has severe weakness and spasticity in both legs. She has to hold on to her husband when she walks.
IMPRESSION: Amyotrophic Lateral Sclerosis.
Continue with Baclofen 10 mg as needed for muscle spasticity along with Rilutek bid. I have recommended patient not return to work. I am doubtful that she can be trained for any type of new job. I strongly urge patient to apply for disability at this time.
Will see patient for follow-up in 2 to 3 months or sooner if needed.
8001 Youree Dr., Suite 500 Louisiana Neurologic Specialties 2015 Fairfield Ave., Suite 2-C
(318) 212-9111 Benjamin B. Nguyen, M.D. (318) 424-3268 Fax (318)424-3280