DATE OF VISIT: MM/DD/YYYY
REASON FOR VISIT: Dizziness and vertigo.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with a history of hypertension, migraines, thyroid disease, hyperlipidemia, who saw us two years ago for evaluation of Parkinson’s disease. However, at that visit, there were no signs of parkinsonism including no signs of bradykinesia, rigidity, postural instability, or tremor, and there was no evidence of cognitive decline to suggest Alzheimer as well. Since that visit, she says that she has been doing well. She continues to have some migraines, and her migraines are atypical in that they distribute with some left-sided numbness in the tongue, cheek, and arm on occasions, but they have been well controlled with Imitrex, and she has been migraine-free for the past two years.
However, she says in the past few months or so, she has continued to have left-sided numbness in her left lip, left cheek, and left arm and sometimes her left leg, not associated with migraines. These episodes last minutes and not more than half an hour. There are no signs of weakness and no other focal neurologic deficits at the time. They started to occur daily since May of this year and so her primary care physician ordered an MRI, which she had at an outside hospital one week ago, for the numbness on her left side to evaluate for stroke. The MRI images were done without contrast and were done without an MRA of her head and neck as well. There is evidence of small vessel ischemic changes and are difficult to view, but there is also a question of some DWI changes, which may be artifact but needed proper ADC, which is to correlate with those, and the small vessel ischemic changes seen did not correlate to the periventricular areas and sagittal images. After this MRI, she says that she felt funny and then woke up the next day in the morning and felt vertiginous, especially when she got up. She said she felt like the room was spinning, but denied any focal numbness, focal weakness, any trouble swallowing or any other deficits. She vomited x1 and went to the emergency department, and at that time, they did not do any further imaging but gave her a dose of meclizine, which improved her vertigo immediately and sent her home with taking meclizine p.r.n. if she would need it.
Since that visit, she had no further episodes of vertigo. She says occasionally she gets lightheaded, and this occurs usually when she is working in the kitchen, does not occur immediately when she sits up or gets up from a seated or lying position, usually resolves within seconds, and she has not passed out. She says that daily she continues to have this left-sided numbness of her left cheek, left lip, sometimes involving her left arm and left leg. She says that occasionally she takes Excedrin Migraine, which seems to relieve the symptoms. She also says that she is wondering if these symptoms are occurring more frequently because she is under more stress with anxiety in her life; however, she is not sure if that is the cause. She comes to us for further evaluation.
PAST MEDICAL HISTORY: Thyroid disease, hyperlipidemia, migraines, osteopenia, alopecia, and irritable bowel syndrome.
MEDICATIONS: Currently aspirin 81 mg daily, amlodipine 5 mg daily, Levoxyl 100 mcg daily, Evista 60 mg daily, meclizine p.r.n. for vertiginous symptoms, omeprazole 20 mg daily, and lovastatin 20 mg daily.
ALLERGIES: Sulfa drugs.
SOCIAL HISTORY: No smoking or alcohol use. She lives by herself. She is not married. She is retired. She maintains an active lifestyle.
FAMILY HISTORY: There is a history of strokes on her father’s side. There is no history of seizures or Parkinson disease or Alzheimer’s in the family.
PHYSICAL EXAMINATION: Orthostatic testing reveals, in a seated position, blood pressure 128/72; pulse 82; in a standing position, blood pressure 130/80 with a pulse of 86. General: No acute distress. Lungs are clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. S1, S2. No murmurs, rubs or gallops. HEENT: No carotid bruits. Neurologic Examination: Mental Status: She is alert and oriented to person, place, and time. Fluent speech. No neglect. Normal naming. Following three-step commands. She is able to do serial 7s without difficulty, and her recall is 3/3 items without cues. Her memory is intact. Cranial Nerves: Pupils equally round and reactive to light. Visual fields are full to confrontation. Extraocular muscles are intact with no evidence of nystagmus. Facial sensation is intact to light touch throughout and temperature throughout. Facial muscles move symmetrically. Tongue protrudes midline. Motor Exam: Normal bulk. Normal tone. Strength is 5/5 throughout with no evidence of a pronator drift. Cerebellar: Finger-nose-finger testing reveals no signs of dysmetria. Gait is normal tandem walk. Reflexes are 2+ throughout with downgoing toes bilaterally.
ASSESSMENT AND PLAN: This is a (XX)-year-old female with a history of hypertension and migraines, who comes in to us today with complaints of left-sided lip, cheek, occasionally left arm or left leg numbness that has been occurring daily. The patient also had a self-limited isolated episode of vertigo one week ago, resolving with meclizine. Given her stroke risk factors of hypertension and hyperlipidemia, it is possible these episodes are due to transient ischemic attacks or strokes, and we recommend a repeat MRI of her brain with proper DWI and ADC correlating images. We would also like this MRI to be done with gadolinium, as these could be episodes fluctuating sensory deficits due to possible multiple sclerosis. Also, in the differential, these episodes could be simple partial seizures with preservation of consciousness. However, the MRI with gadolinium will give us a better understanding if there is any structural abnormality that may predispose her to seizures. We would also like to take a look at her head and neck vessels, and we recommend an MRA of her head and neck to evaluate her cerebral and extracranial vasculature. It is possible that these episodes may be due to stress and anxiety in her life. However, we did hyperventilate her about 1-1/2 minutes, and these did not reproduce the symptoms of left-sided numbness in her left cheek or her left arm. Therefore, we will defer this as a diagnosis of exclusion after further studies are undertaken. We would like to follow up with her after these studies are completed.
