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Assessment
(Robert W Dow, MD - June 3, 1992)

BURNS, JOLYNNE

REFERRING PHYSICIAN:  Peter Morgan.

06/03/92: Ms. Burns is a young woman who I saw in the hospital in late April, 1992, because of psychotic illness and an abnormal neurologic examination.  She attends with her mother today and the reason for this return visit is not really clear to me, the patient, or her mother.  She is now taking Haldol, Zoloft, and Cogentin.   She has developed some symptoms referable to the Haldol and the Cogentin has been started recently.  There is a suspicion that I am to see her regarding the extrapyramidal symptoms.  The other concern is what is wrong with her gait.

First of all, the extrapyramidal symptoms seem to have been rather mild from the description and very well controlled with the Cogentin.  She is taking it more or less on a p.r.n. basis up to twice a day and the medicine seems to be very effective.

In terms of the gait problem, in the hospital it was my impression that she had always been a clumsy individual and had always had a problem with her gait.  This was present in high school because at least on teacher made the comment that she had a "faulty gyro."  However, it seems that prior to that she was involved in marching band and cheerleading and got along okay in that regard.  In talking with her mother, there was nothing unusual about the birth, though the pregnancy was complicated by vaginal bleeding at about the sixth month and she spent the last three months of pregnancy in bed.  Still birth weight was normal and development was all reached in a timely fashion.  She was maybe a bit delayed in toilet training, but it is hard to say what this means, of course.  No other family members have similar problems with their gait.

A repeat neurologic exam was performed.  Her mental status is much improved in that she is awake, alert, and not acutely delusional at this time.  Her cranial nerves are normal II-XII, though she has mild articulation disturbance.   Funduscopic and visual fields are normal.  Motor testing shows symmetric tones, strength, and no drift.  Deep tendon reflexes are brisk but symmetric.   The toe signs are downgoing.  There is no drift present.  Sensory examination showed normal pinprick, vibratory, and position sense.  Coordination testing revealed no clear-cut ataxia on finger-nose-finger.  Rapid alternating movements were performed somewhat slowly and are mildly incoordinated.  Her spontaneous gait has a base of about eight inches or thereabouts and tandem gait is unsteady.   Romberg sign is absent.  In the hospital, she had an MR of her brain and an EEG, both of which were normal.

This individual is left handed and has long had difficulty learning to do manual tasks.  This has always been attributed to her being left handed and having to convert from right handed instructions to left handed practice.

My impression is that this individual probably has very mild cerebral palsy.   I also think that she has some mild extrapyramidal side effects that are well controlled with Cogentin.  I neglected to mention that there is no tremor present on observation and no substantial bradykinesia or cogwheeling except with distracting maneuvers when she has modest cogwheeling in both wrists.

At this point, I don't think that further neurologic investigation is warranted in that there is no clear evidence for a progressive neurologic illness in the history or physical examination.  It is concerning that she developed the psychotic illness and a little more trouble with her walking, but I would think that this is likely related to drug effect rather than a degenerative neurologic process.

I have not scheduled are return visit, but I'll be speaking with Dr. Morgan and Dr. Smith tomorrow to be sure that I have addressed the proper question.

Thank you for asking me to see this patient.

Robert Dow, M.D./fmx
DD: 06/03/92
DT: 06/05/92

cc: Peter Morgan, M.D.
     Michael Smith, M.D.
     RWD File