DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Physiatric evaluation and management of the patient with multiple sclerosis and gait disorder.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-handed gentleman who is referred by his primary neurologist for physiatric evaluation of problems with gait and stance. The patient reports that he was only recently diagnosed with multiple sclerosis after what appears to have been symptoms for several years. He does not give a great history, but it appears that approximately five years ago, after he suffered a right ankle fracture, he had a very difficult recovery from this injury.
He apparently had difficulty ambulating for over five months and eventually was able to move on to a cane. He thinks that during that time, he was flexed forward quite a bit and leaning on a cane and thinks that might have resulted in his gait disorder. Regardless, he has had a progression of his trunk flexion and rotation as well as his impairment in walking over the past five years such that he has great difficulty even doing his daily activities.
The patient had radiographic studies, which showed demyelinating lesions throughout the central nervous system, including the brain, cervical and thoracic spine with and without gadolinium. There were no gadolinium-enhancing lesions. He was seen by Dr. Jane Doe, who did not find any evidence of optic nerve involvement. He says to me that he thinks the lower extremity weakness and gait problems are his primary symptoms with MS. He gets fatigued very easily. He can only stand for short period of time and then has to sit down for a while before he can get up and move around again. It takes him about an hour to do his morning activities of daily living. He does not have a lot of energy for much else, including working, because of the difficulty of his mobility and activities of daily living.
He does have some urinary urgency and frequency. He denies any swallowing and speech difficulties. He is not sure if he has noted any cognitive decline but thinks that he does not have as much interest in academic pursuits or work-related issues because daily activities are taking all of his energy.
PAST MEDICAL HISTORY: Multiple sclerosis, history of infertility, testosterone deficiency, BPH, hypogonadism, status post right ankle injury, history of Clostridium difficile, and history of xanthogranuloma of the nose.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: Vitamin C 1000 mg b.i.d., vitamin D 1000 international units daily, multivitamin, and simvastatin 10 mg at bedtime.
FAMILY HISTORY: Question of MS in his mother who died at age 80 and apparently had developed a neurologic problem.
FUNCTIONAL HISTORY: The patient is independent in all mobility without an assistive device and with all self-care activities. He does drive and does some housework and meal preparation. He also works part-time doing some work for his wife. They have one child. He does not smoke, drink or use recreational drugs.
REVIEW OF SYSTEMS: The patient reports loss of energy, pain in his right hip posteriorly, some pain in the arms and legs proximally, some right ankle pain from time to time, and occasional numbness in the feet bilaterally. Remainder of review of systems is negative.
PHYSICAL EXAMINATION: On general examination, the patient is a well-developed, well-nourished gentleman in no acute distress, appearing younger than stated age. Blood pressure is 136/80, pulse 72, and weight is 205 pounds. Pain score is 3/10 with bilateral left ankle pain and right lower back, buttock pain.
Examination of the spine reveals him to have significant scoliosis. His trunk is essentially in forward flexion, primarily at the hips, but slightly in the thoracic spine as well. His entire spine is shifted to the left with a mild rotational component. When given cues, both physical and verbal, he is able to correct most of the spine deformity. However, he states that he feels a strain when he tries to stand erect and more symmetric and his position of comfort is in this forward flexed, left shifted and rotated position.
It is difficult to tell if there is a leg length discrepancy, but the pelvis generally appears to be level. In the supine position, he is able to lie completely flat, although there is still a mild shift of the spine with slight pelvic obliquity in the spine position as well. Extremity examination reveals mild edema at both ankles. There is no calf edema, but there is slight tenderness in the left calf around the insertion of the Achilles tendon when compared to the right.
Range of motion is reduced in both the lower extremities, particularly at the hamstrings. Straight leg raising is only about 45 degrees bilaterally as a result of hamstring tightness. Hip flexion and external rotation is mildly reduced as well. He has decreased range of motion at both ankles for both dorsi and plantar flexion.
On neurological examination, he is awake, alert, and oriented. Mental status appears to be within functional limits. There is no problem with receptive or expressive language skills. Mood is good and behavior is very appropriate.
Cranial nerve examination today reveals extraocular movements to be full without nystagmus. Pupils are equal, round, and reactive to light to light and accommodation. He has slight asymmetry of the face with decreased nasolabial fold on the left compared to the right. However, there is no asymmetry with smile or with the patient puffing his cheeks. Tongue protrudes to midline. Palate elevates symmetrically. Shoulder shrug is intact.
On motor testing, the patient has essentially normal strength in both upper extremities to manual muscle testing. Lower extremity strength is essentially 4+/5 to 5/5 on the right and 4/5 to 4+/5 on the left. There is slight asymmetry with weaker left hip flexors, left hamstrings, and left tibialis anterior when compared to the right.
Coordination is reduced on finger-nose-finger testing in the left upper extremity with mild dysmetria; it is intact in the right upper extremity. Toe tapping is reduced in both lower extremities, but left side is slower and with less amplitude than the right side. Toes are upgoing bilaterally in Babinski testing. Deep tendon reflexes are somewhat hyperactive bilaterally, but there is no clonus at the ankles.
Sensation is reduced to pinprick in both lower extremities in a patchy distribution in the feet and lower legs. Joint position sense is intact at both great toes.
Gait is with postural problems and with a narrow base of support. There is decreased balance as a result of these two problems. The patient’s trunk is also quite weak. He had a great difficulty doing a bridge exercise in supine and was not able to pick up his shoulder off the examination table in attempting an abdominal crunch.
IMPRESSION: The patient is a (XX)-year-old gentleman with what appears to be primary progressive multiple sclerosis. He is also status post a right ankle injury and appears to have some degenerative changes in the left ankle as well perhaps related to chronic instability from weakness. His neurological examination reveals him to have more symptoms on the left compared to the right with decreased coordination and slightly greater weakness. His main problem, however, is his posture with significant trunk weakness.
RECOMMENDATIONS: The patient recommended physical therapy to work on his trunk and lower extremity strength and coordination. He was given a prescription for physical therapy twice a week for six weeks to work on bilateral lower extremity stretching and strengthening exercises, especially stretching of the bilateral hamstrings and Achilles tendons and strengthening of hip extensors, abductors, quadriceps and tibialis anterior bilaterally.
Prescription also asked for trunk flexibility and strengthening exercises both for flexors and extensors, as well as postural training. He was asked to start working on light aerobic exercise program with a stationary bicycle or an elliptical machine. He will also be receiving gait training to improve symmetry of gait and posture. He has agreed to do a home exercise program regularly to improve and maintain his functioning in these areas. Followup with us will be in about two to three months. The patient was seen for a total of 60 minutes with the visit beginning at 3 p.m. and ending at 4 p.m. Greater than 50% of the time was spent in education, counseling and coordination of care.
