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5. Neurological History by Dr. Light, August 2, 1932

NEUROLOGICAL HISTORY AND EXAMINATION

Aug. 2, 1932.

Dr. Light.

COMPLAINT

  • Headache, slow speech, double vision and failing vision, tinnitus and forgetfulness with earliest symptom 3 months ago.

PRESENT ILLNESS

  • 1. Headache - Although she has had occasional headaches all her life the pain which she associates with the P.I. first came on about three months ago in the suboccipital and in the vertical regions. These were frequent and distressing, and associated with stiffness and tenderness in the back of the neck. She cannot remember whether they came on more often in the morning than in the evening.

  • 2. Hot flashes - She underwent artificial menopause eight years ago after removal of the uterus, tubes and ovaries, apparently for fibroids. Immediately after the operation she began having hot flashes, which she describes as a sudden flush, a breaking out in a sweat over the entire body, a feeling of warmth and of weakness. She had these for a year or two, and then they virtually disappeared to recur definitely within the last three months. She sometimes has several in a day. They are associated with tinnitus and headache.

  • 3. Tinnitus - Occurring in both ears, but chiefly on the left, has been a disturbing feature. It is a continuous buzzing noise, which makes her feel as though her head would split. It comes almost every day.

  • 4. Failing vision - As far back as 2 months ago she consulted an oculist because of beginning failure of eyesight. Glasses did not relieve the complaint and for the past month she has known that there is a defect in the temporal field of the left eye, and more recently the right eye has begun to lose its temporal vision. Simultaneous with these field defects there has appeared diminished visual acuity, so that reading become difficult.

  • 5. Double vision - Has been present occasionally during the past week.

  • 6. Visual hallucinations -- For several weeks she has seen dark spots passing in front of her eyes, but during the past 2 days she has noticed what she describes as vertical black and white stripes; she does not know which eye they occur in, but she recognizes that they are chiefly in the left visual area.

  • 7. Forgetfulness - and Slowing Mentality - Beginning perhaps two months ago she began to forget such things as the subject of the conversation which she was engaged in, or even the last half of a sentence on which she was begun. She thinks that she has been somewhat depressed over this and the other symptoms. She has slept poorly at night and has been drowsy during the daytime for as long as 3 months ago, when a period, of perhaps a month, occurred, when she would fall asleep whenever she sat down. Associated with her forgetfulness and her lack of concentration has come slow speech, which appeared first about 4-5 weeks ago.

  • 8. Questionable aphasia - Although she describes an increasing inability to think of the right word, nothing of the sort has been noticed since she arrived in the hospital and I suspect that her trouble has been generalized slowing of the mental processes.

  • 9. Paresthesias of the left side of face - For several seeks she has had burning feelings over the left side of the face, as though it had been scalded, and during these times it is sore to touch. The left ear has ached on 1-2 occasions.

  • 10. Clumsiness of the right hand - For 3-4 weeks she has been increasingly clumsy in the use of the right hand. She has let dishes fall, and has found that her writing ability is less good.

  • 11. Nausea and (on the ward) vomiting - Nausea has also appeared with the headaches, but did not go on to vomiting until last evening after arriving in the hospital, and she has a short spell. Again this afternoon vomiting appeared, and the examination was cut short this evening because on sitting up she became sick.

NEUROLOGICAL EXAMIANTION

  • Personality Note - The woman is a pleasant, cooperative person in possession of all of her faculties, but with retarded though (sic), and making a visible effort to follow the conversation, and to return correct answers. Her memory is not impaired to the point where the examination is made unreliable, but she recalls things only with some effort. She speaks slowly but without any trace of using the wrong words. She is a woman of 43, whose husband is alive and well, but is unemployed, although his usual occupation is concerned with the manufacture of automobile parts. She has 2 children, a boy and a girl, who are well, and lost one boy at the age of 3 1/2 of diphtheria. There were no miscarriages. Since arriving on the ward yesterday she has slept a good part of the time and has been in a state of apathy even when awake.

  • Skin - Fine in texture, without unusual pigmentation, naevi or moles.

  • Hair - Normal in amount and distribution.

  • Perspiration - No unusual.

  • Head - Normal in size and shape, and does not exhibit dilated veins, exostoses, abnormal pulsations, tenderness to percussion, cracked pot sound, or bruit.

  • Neck - Somewhat tender especially on the right side, in the suboccipital region, and is slightly rigid.

CRANIAL NERVES

  1. Olfactory

    • Subjective - No history of hallucinations of smell or loss or impairment of function.

    • Objective - She responds equally well to test odors on the two sides.

  2. Optic

    • Subjective - History of failing vision, both as to acuity and as to bitemporal defects. The field loss first appearing in the left eye. Hallucinations of the light in the form of dark spots for several weeks, and of vertical black and white stripes during the past 2 days.

    • Objective - Visual acuity O.S. 20/40 with extensive temporal defect. O.D. 20/40 with slight temporal defect and large scotoma stopping exactly at the midline in the inferior quadrant. Fundi - Discs: - on examination in the out-patient-department 5 days ago there was 1 D. choking in the left disc, but the right one seemed to be flat. There was at that time optic pallor of both discs, chiefly on the left side. At the present examination the pupils are dilated and the discs are easily seen, showing 3-D of elevation of the left with engorged veins and fullness of the physiological cup. No hemorrhages are seen. On the right side the papilloedema is less, measuring between 1-2 D, but the veins are full, and the margins of the disc are hazy.

  3. Subjective - History of transient diplopia during the last week or two.

  4. Objective - Pupils are unequal, the left being slightly smaller than the right, and irregular in outline. Both react to light, both direct and consensual, and to accommodation, but the reaction on the right side is more active. The external ocular movements are normal, and there is no nystagmus or exophathalmos. The left palpebral fissure is slightly larger than the right.

  5. Trigeminus

    • Subjective - History of burning pain in the left side of the face, and the ear but no numbness on the face.

    • Objective - Sensory - there is no evidence of anaesthesia or hypesthesia over the face, although the patient's responses to sensory determinations are not as reliable as we desire. Corneals are equal and fairly active on both sides. There is no deviation of the jaw or weakness or paralysis of the temporal or masseter muscles.

  6. Facial

    • Subjective - No history of taste disturbance, facial palsy, spasmodic contractions of the facial muscles or disturbances of the lacrimal secretions.

    • Objective - Motor - Facial expression shows a very slight weakness of the right lower facial muscle. There is nothing abnormal about the lacrimal secretions or the taste.

  7. Acoustic

    • Cochlear

      • Subjective - History of tinnitus, chiefly in the left ear, but not of deafness.

      • Objective - The hearing is equally good in the two ears, but as to air and bone conduction, but midline bone conduction is referred chiefly to the right ear.

  8. Glossopharyngeal

    • Subjective - History of slow speech but not of dysarthria or dysphagia.

    • Objective - Pharyngeal reflex active.

  9. Vagus

    • Subjective - No history of regurgitation of fluids or projectile vomiting. There has been slowing of speech.

    • Objective - No deviation of the soft palate. Pulse rate is 80, regular, equal in the two wrists.

  10. Spinal Accessory

    • No weakness or paralysis of sternocleidomastoid or trapezius muscle.

  11. Hypoglossal

    • No weakness or paralysis of the tongue. It protrudes in the midline without tremor.

CEREBRUM

  • Frontal
  • Memory is said to have been poor during the past three months altho she is well oriented as to time, place and person now and gives a fairly adequate story if given time to think it out. Cerebration is obviously slowed, and concentration somewhat difficult. There is no state of euphoria, but she has been somewhat depressed lately over this condition. No history of change in habits or anosmia.

  • Temporal
  • There is history of aphasia, but nothing of the sort can be elicited at present. No evidence of uncinate gyrus syndrome. Perimetric fields show bitemporal hemianopsia, not complete.

  • Precentral
  • No history of convulsions, paralysis or paresis, but she speaks of a clumsiness of the right hand and this is brought out by the tests of coordination. There is no objective loss of muscle tone or power.

  • Paracentral
  • There is no astereognosis, loss of muscle sense or apraxia, nor loss of tow-point determination in either hand.

  • Postcentral
  • Sensation of touch (pinprick) is diminished over the whole of the right leg area below the knee, as well as in the right forearm and hand and in the left forearm and hand. There are no demonstrable changes in the face or on the trunk.

  • Occipital
  • History of hallucinations of light and hemianopsia. That latter is bitemporal.

BASAL GANGLIA

  • No athetosis, tremors, loss of plastic tone, retropulsion, perseveration (sic), deviation of the head or emotional disturbances. There is a loss of associated movements of the right hand.

CEREBELLUM

  • Station, Romberg and gait were normal at examination 5 days ago.
  • Choked disc of 3 D. on the left, 2 on the right.
  • No evidence of hypotonicity.
  • Finger to finger, finger to nose tests were performed with slight ataxia of both sides. Finger to thumb test performed well with both hands. No pastpointing.
  • There is a definite adiadococinesia of the right hand.
REFLEXES

  • Superficial
  • Corneals, abdominals are equal and active. Plantars active on the left. The stroking of the right plantar surface imparts a flexion reflex until the stick reaches the head of the metatarsal when the large toe suddenly extends and the smaller toes stand out. There is no Oppenheim or Gordon.

  • Deep
  • Biceps, triceps, knee and ankle jerks are all exaggerated, but there is not much to choose between the two sides, although at times the left knee jerk and biceps seems a little stronger than the right. There is no sustained ankle clonus although the left ankle can be made to give an extra jerk on sudden flexion.

VASOMOTOR

  • There is nothing remarkable seen on the ward, although she gives a history of hot flashes; sweats, feeling of weakness, flushing and a feeling of warmth.
SPINCTERS

  • Sphincters well controlled.
PERIPHERAL FINDINGS:

  • - Definite hypesthesia over the right arm and right leg, and the left forearm and hand. There are no evidences of loss of power. Heart is not enlarged. Sounds are normal but faint. Pulse rate is 76-80. Blood pressure is 120/88.
PITUITARY SYMPTOMATOLOGY:

  • NEIGHBORHOOD
    1. Headaches suboccipital and vertical as the chief complaint.

    2. No evidence of third nerve changes except for more reaction in the right pupil than the left, and slight irregularity of the left pupil.

    3. Sella turcica not enlarged although there is slight atrophy of the clinoid.

    4. No history of epistaxis or rhinorrhea.

    5. No anosmia.

    6. No uncinate syndrome.

    7. Fundi - shows pallor of the disc, left, five days ago with beginning choking and there is now present papilloedema of 3-D on the left, 2 on the right.

    8. There is definite bitemporal hemianopsia, chiefly in the left side but with a large scotoma on the right, which ends exactly in the midline.

  • GLANULAR
    1. Temperature normal. Pulse between 70-80 on the ward.

    2. Cerebration definitely slowed with tendency to somnolence at various periods during the past three months.

    3. Height 157 cm. Weight 60.2 kilograms, which seems to be a normal proportion for this woman.

    4. No prominence of the jaw or offsetting of the teeth.

    5. Hands and feet are normal.

    6. Hair - Distribution and texture is normal.

    7. Basal metabolism -

    8. Genital development was normal although there was artificial menopause from an apparent hysterectomy 8 yrs. Ago.

    9. No polydipsia or polyuria.

    10. There has been an avoidance of sweets, although recently she has had a rather large appetite for other things.

  • POLYGLANDULAR

    1. Thyroid - No history of tachycardia, palpitation, tremor, diarrhea or goiter.

    2. Adrenals - No weakness or pigmentation.

    3. Pancreas - No evidence of diabetes.

SUMMARY OF POSITIVE FINDINGS

  • Subjective

    1. Headaches, suboccipital and in the cervix - 3 months.

    2. Failing vision, 2 months with diminished acuity and bitemporal hemianopsia, beginning in the left eye.

    3. Visual hallucinations consisting of dark spots, and later of black and white stripes.

    4. Diplopia - transient attacks beginning a week ago.

    5. Forgetfulness, drowsiness and slowed mental processes for the past two months.

    6. Questionable history of aphasia, the difficulty probably being retardation of thought.

    7. Paresthesias of the left side of the face and left ear.

    8. Increasing clumsiness or right hand - 1 month.

    9. Return of "hot flashes", now appearing several times daily, similar to those experienced after artificial menopause 8 yrs. Ago.

    10. Nausea 4 weeks, and vomiting since coming to the ward.

  • Objective

    1. Drowsy, slowly-reacting person who concentrates with difficulty but is not disoriented.

    2. Slight rigidity of neck with suboccipital tenderness, chiefly on the right.

    3. Bitemporal hemianopsia, chiefly of left eye, with slightly reduced visual acuity and large scotomata.

    4. Bilateral papilloedema. O.D. 2 D., O.S. 3 D. Increasing rapidly since visit to O.D.D. 5 days ago.

    5. Anisocoria, right pupil larger than left with slowed reaction of left, and irregular outline.

    6. Slight widening of left palpebral fissure, with very slight right lower facial weakness.

    7. Bilateral ataxia on finger to nose and finger to finger test, but with adiadococinesia of right hand only.

    8. Hypesthesia of right forearm and hand, and right leg below the knee, and of left forearm and hand.

    9. Hyperactive reflexes throughout, possibly more active on left. Unsustained clonus of left ankle. Suggestive Babinski of right foot.

IMPRESSION

  • The progress of the disease has been fairly rapid and the tumor is probably a malignant glioma. The motor and sensory findings suggest a bilateral lesion, possibly extending along the corpus callosum. The bitemporal hemianopsia does not fit well with the other findings but it may be due to papilloedema. Suggest ventriculography.

(Dr. Light)

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