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Assessment
(Eugenio Matos, MD - November 25, 1992)

HISTORY SHEET

DATE:   11/25/92

PATIENT: BURNS, JOLYNNE
PHYSICIAN:  Eugenio Matos, M.D.

NEUROLOGY CONSULTATION:

REFERRING PHYSICIAN:  Brian Levy, M.D.

Mrs. Burns is a 27 year old white female with a history of psychiatric disorder.   In the past she has been on Haldol and Zoloft.  She was admitted to Presbyterian Hospital in April, 1992 because of psychotic episodes.  At that time she had an EEG and MRI of the head which were normal.  She was evaluated by Dr. Dow at that time who found mild articulation problems, slight dysmetria on cerebellar testing, and a wide based gait.  She was seen again by Dr. Robert Dow in July, 1992 with essentially no change in her neurological exam.  Dr. Dow's impression at that time was that the patient had cerebral palsy.  During those evaluations the patient had been taking Haldol as well as Zoloft.  The patient is here for follow-up regarding her coordination and gait problems.  She denies new complaints and denies also changes in her gait, coordination, or overall status.  She currently is on no medications except birth control pills.  She denies further problems.

PAST MEDICAL HISTORY: As above.  As a child, 5 years old, she fell from a pick-up truck, hit the back of her head, and was unconscious for five minutes.  This is no history of seizures.  There is no family history of degenerative diseases.  The patient does not drink or smoke. 

REVIEW OF SYMPTOMS: Otherwise negative.  She denies specifically bowel or bladder dysfunction.

NEUROLOGICAL EXAM:
MENTAL STATUS: The patient is alert and oriented.  Speech is essentially normal, although the rhythm of speech and articulation at times are slightly slow.  There is no obvious aphasia. 

CRANIAL NERVES: Cranial nerves II-XII are normal.  Visual field and funduscopic exam are normal.  There is no nystagmus.

MOTOR EXAM: Normal strength and mass in upper and lower extremities.  The lower extremities are spastic.  No involuntary movements.  No rigidity, cogwheeling, or tremors.

REFLEXES: 3/5 in the upper extremities and 4/5 in the lower extremities.  Plantar responses are flexor bilaterally.

CEREBELLAR: There is terminal tremor and dysmetria, minimal in finger-nose-finger.   Heel-knee-shin test is also slightly ataxic bilaterally, slightly moreso on the left.  Romberg test in negative.  The patient is able to tandem gait with some instability but does not fall to either side. Gait is wide based, spastic, and the patient frequently slaps her feet on the ground.  She is able to turn around without difficulty and otherwise her gait is steady.

SENSORY EXAM: Normal to primary and cortical sensation.

NECK: There are no corotid bruits.

HEART: Regular rhythm with no murmurs.

LUNGS: Clear.

EXTREMITIES: There is no calf tenderness or peripheral edema.

IMPRESSION: Cerebral palsy.  The patient has ataxic and spastic features, more prominently in the lower extremities.  No changes in her neurological exam compared to previous exam by Dr. Dow in July and June, 1992.

PLAN/RECOMMENDATIONS: I have no further recommendations at this point. I explained to Mrs. Burns that a follow-up exam in six months would be helpful to have a better idea of any changes over a longer period of time.  She will call me if new problems arise.

                                     Eugenio Matos, M.D./awc
DD: 11/25/92
DT: 12/01/92

cc:  Eugenio Matos, M.D.
      Brian Levy, M.D.