tokens: 351853846 WGH 8921553 92855 715722 3/24/1997 12:00:00 AM GAIT DISORDER . Unsigned DIS Report Status : Unsigned DISCHARGE SUMMARY NAME : PREHEPRIOR , NIENEMILEISELE UNIT NUMBER : 372-41-54 ADMISSION DATE : 03/24/97 DISCHARGE DATE : 03/28/97 PRINCIPAL DIAGNOSIS : Gait disorder . HISTORY OF PRESENT ILLNESS : The patient is a 31-year-old right-handed female with right-sided greater than left-sided weakness and difficulty walking for several days . She was in her usual state of health until 3/20/97 when she experienced the fairly sudden onset of predominantly right-sided arm and leg weakness and ataxia . She was standing and walking with her friend , who &quot; had to catch her from falling down &quot; as she toppled towards the right . She evidently recovered from the episode after a number of minutes . The following day , she remained in bed through essentially all of the day due to malaise with no specific deficits being noted . In the subsequent two days , she had several small spells of &quot; imbalance &quot; , particularly towards the right , and other symptoms included diffuse and mainly frontal headaches and mild neck soreness . There was no diplopia , visual loss , speech abnormality or sensory change in her history . She was initially evaluated at an outside hospital emergency room , and then transferred to Well General Hospital . PAST MEDICAL HISTORY : Is notable for depression , and she has been followed regularly by Dr. Freiermchird of Nash Health for several months with pharmacologic treatment , which is apparently working well . Her Doxepin has recently been increased . She is status post appendectomy and otherwise has no remarkable past medical history . ALLERGIES : Quinine gives her a rash . MEDICATIONS ON ADMISSION : The only medications she is on are Paxil 30 mg p.o. q.day , Doxepin 25 mg p.o. q.day , and Klonopin 2 mg p.o. q.h.s. SOCIAL HISTORY : She is currently unemployed , but until recently , she was employed at a bank . She was born and raised in Atonlaremont Rockpo . There is a history of childhood abuse . She does not drink . She is a former tobacco user and takes no illicit drugs . PHYSICAL EXAMINATION : She was pleasant , in no acute distress ; blood pressure 130/60 ; heart rate 66 ; respirations 18 ; temperature 98 . Her thyroid was within normal limits . There were no carotid or cervical bruits . She had a normal S1 and S2 and regular rate and rhythm with no murmurs . Her lungs were clear to auscultation bilaterally . Her abdomen was benign . Her extremities were without clubbing , cyanosis , edema , or rash ; there were some older hematomas in the bilaterally shins . Mental status - her speech was fluent without errors . Her affect was slightly inappropriate at times ; for example , singing or humming along while performing some of the motor tasks and giving the impression of indifference to the deficits that were demonstrated on the examination . Her memory was fully intact for short-term recollection of three out of three objects at five minutes with excellent naming , repetition , proverb interpretation , and ability to follow commands . Visual fields were full to confrontation . Her left pupil was 7 mm reacting to 5 mm . Her right pupil was 5.5 mm reacting to 4 mm . Her extraocular movements were intact for horizontal and vertical pursuits . There was no nystagmus and no ptosis . Her saccades were normal . Facial strength and sensation were full and symmetric . Her tongue , uvula and palate were midline . Shoulder shrug was 5/5 power . Motor examination revealed 5/5 power in all groups in the proximal and distal upper and lower extremities . There was no drift . There was normal bulk and tone . She had slightly slow fine finger motility approximately equal bilaterally , although this was extremely difficult to reproduce . Sensory - intact light touch , temperature , and vibration overall . Reflexes were 2+ throughout in the upper and lower extremities , and toes were downgoing . There was no jaw jerk and no Hoffman &apos;s sign . Coordination - toe tap was slow bilaterally , although difficult to reproduce , and at best , was essentially within normal limits . On standing , she tended to fall to the front , back or sides without trying to stop her fall initially , and extensive gait testing was deferred due to concerns for safety . Her heel-to-shin and finger-to-nose testing was fully intact bilaterally without ataxia or tremor . LABORATORY DATA : Were unremarkable with normal electrolytes and complete blood count parameters . Her erythrocyte sedimentation rate was 12 . Her coagulation parameters were normal . Head CT scan without contrast showed normal brain parenchyma and no intracranial process . HOSPITAL COURSE AND TREATMENT : The patient was admitted for her gait disorder with other notable findings on examination including anisocoria , which , by the patient &apos;s report , had been noted several months earlier . A magnetic resonance imaging and magnetic resonance angiogram study was obtained , which showed no clear evidence of arterial dissections or infarction or other pathologic processes . She had been placed on heparin initially , but this was discontinued after the magnetic resonance imaging results were obtained . Posterior transcranial Doppler studies showed normal studies of both vertebral arteries , and carotid non-invasive studies showed normal right and left carotid bifurcations . On the second hospital day , her gait continued to be markedly unstable , although with no consistent pattern in terms of weakness or directionality of falling , and she continued to have no reproducible upper extremity or lower extremity ataxia or dysmetria . She was seen by the Psychiatry Service . She was not felt to be acutely suicidal or otherwise in need of acute psychiatric treatment . The psychiatrist also noted the indifference the patient evinced regarding her own symptomatology . The patient was evaluated in one of the neurology conferences for several hours , and during this time , showed significant improvement while receiving gait training as well as evaluation ; in particular , she became more stable with counter-balancing methods . This trend of improvement continued , and she was discharged in stable condition . She will follow up with her psychiatrist , Dr. Freiermchird ( Sone Memorial Hospital ) on a regular basis , and she can follow up with the Neurology Service on a p.r.n. basis if needed . She will continue on her previous outpatient medical regimen . NIREGE MEMORY , M.D. TR : bzo DD : 03/29/97 TD : 03/31/97 12:36 P cc : NYRI A MEMORY , M.D. ASHELLRIETTE NESSASU THREATSVOT , M.D. EJEAN NADARC FREIERMCHIRD , M.D.