is a right-hand-dominant, 15-year-old female, who reports arm weakness when
playing her flute and styling her hair. Onset was 2 months ago and it is
progressing. More recently she has difficulty running and swallowing. Twice
she has had horizontal diplopia for 15 minutes. Resting helps some. She
denies numbness, bowel/bladder change or cognitive difficulties.
PMH: Reactive airways disease.
Family History: Negative.
Social History: Home schooling, her mother has custody,
parents divorced. No alcohol, tobacco or drug use.
ROS: Rhinorrhea, neck and back pain, weight loss
BP 88/40 HR 72
General: Thin. Mild distress.
Mental Status: Alert and oriented x 3. Speech without
dysarthria, but with nasal quality.
HEENT: Her head is normocephalic and atraumatic. Neck
supple, with full range of motion. Weak neck extension and flexion. Pupils
were equal, round and reactive to light. Extraocular movements were intact
without nystagmus. Facial sensation was intact in the V1 through V3 distributions
bilaterally. Normal jaw strength. Moderate facial weakness with eye closure
and holding air in cheeks. The palate elevated symmetrically. The tongue
was midline without fasciculations. Sustained upgaze was equivocal for
ptosis after 90 seconds.
Motor (Power/Tone/Bulk): Strength bilaterally: 4/5 biceps,
deltoids, triceps; 5/5 wrist flexors, wrist extensors, interossei; 4/5
hip flexors and hip extensors; 5/5 knee extensors and knee flexors; 3/5
ankle dorsiflexors; and 4+/5 ankle plantar flexors. Unable to stand from
seated position without assistance.
Sensory: Sensation was intact to light touch, pin prick
and proprioception bilaterally in the upper and lower extremities. Romberg
Reflexes: 2+ at the biceps, triceps, brachioradialis,
patella and Achilles. Toes were downgoing to plantar stimulation bilaterally.
Coordination: Finger-to-nose poor secondary to weakness,
and rapid alternating movements were intact bilaterally.
Gait: Labored with bilateral foot drop.
Abnormal Movements: None.
Other Organs: Noncontributory.