REASON FOR CONSULTATION: Left lower extremity weakness.
HISTORY OF PRESENT ILLNESS: History was obtained from the patient and also from the patient’s daughter. The patient is a (XX)-year-old right-handed female who was admitted because of worsening bilateral lower extremity edema, inability to walk, and also with history of mental status changes. The patient was found to have atrial fibrillation and atrial flutter. She was started on anticoagulation therapy. She was also treated with a diuretic. Her lower extremity edema has significantly improved, but she continues to complain of weakness in the legs.
According to the patient’s daughter, the patient had been having increasing weakness in the lower extremities for several weeks. Initially, she was using a cane, then a walker, and lately, she has been wheelchair bound. She denies any significant pain in the legs, back pain or headaches. She has control of bladder and bowel function.
Recent workup also revealed multiple liver lesions, possibly metastatic. The patient is to have further workup, including CT of the chest, abdomen, pelvis, mammogram, and also ultrasound-guided biopsy of the liver.
PAST MEDICAL HISTORY: Significant for history of diabetes mellitus, hyperlipidemia, osteoporosis, arthritis, and recently diagnosed atrial fibrillation.
MEDICATIONS: Zocor, hydrochlorothiazide, benazepril, Fosamax, glyburide, and Toprol-XL.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient was apparently living by herself. There is no history of tobacco, alcohol or illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: A 12-point system review revealed no additional pertinent information except for what is reported in the history of present illness, including progressive edema of the lower extremities for the last several weeks, decreased appetite, and multiple falls.
PHYSICAL EXAMINATION:
GENERAL: The patient is an obese elderly female who is not in any apparent distress.
VITAL SIGNS: Blood pressure 114/46, pulse 64 per minute, respirations 20, and temperature 98.8.
NECK: Supple.
HEENT: Head is atraumatic and normocephalic.
CHEST: Clear.
ABDOMEN: Soft.
EXTREMITIES: There is moderate bilateral pedal edema. Peripheral pulses are present but poor.
NEUROLOGIC EXAMINATION:
MENTAL STATUS: The patient is alert and oriented. Speech and language are normal.
CRANIAL NERVES: Pupils are postsurgical bilaterally but reactive to light. Extraocular movements seem intact; although, upgaze is limited. Face is symmetrical. Tongue is midline.
MOTOR: Strength is 5/5 in both upper extremities. In the lower extremities, proximal strength is 4-/5 of hip flexors, 4/5 of knee extensors and knee flexors, 2/5 dorsiflexor on the right side and 0/5 on the left side. Plantar flexor is 4/5 bilaterally. Deep tendon reflexes are absent throughout. Tests of coordination are normal in the upper extremities but difficult to perform in the lower extremities. Gait could not be tested.
SENSORY: Sensations are decreased to pinprick and touch up to the ankles bilaterally. There is tenderness over both calves as well as over the fibular heads.
LABORATORY DATA: Recent labs were reviewed. B12 level, TSH, and serum protein electrophoresis is normal. BUN and creatinine are elevated. The patient is being followed by renal service for that.
IMPRESSION:
1. Paraparesis, left side more involved than right. There is probably bilateral superimposed footdrop, left side worse than the right.
2. Probable diabetic peripheral neuropathy.
3. Possible metastatic lesion in the liver.
4. Encephalopathy, which seems to have improved.
RECOMMENDATION: Given multiple lesions in the liver, we recommend doing MRI scan of the brain with contrast and MRI of the lumbosacral spine to rule out metastatic disease. We will have physical therapy evaluate for paraparesis and also for AFOs. If above investigations are negative, may consider doing NC/EMG study of the lower extremities.
