SUMMARY Decreased visual acuity, left eye. Pattern shift visual evoked potential study within normal limits.
Normal brain stem auditory evoked potential study.
Saccadic eye movements are well organized in the horizontal and in the vertical directions. Gaze and fixation testing, including straight gaze, gaze to the left, gaze to the right, and gaze upward and downward, produces no nystagmus. The oscillating tracking test reveals well-organized horizontal pursuit movements to each side.
Bidirectional opticokinetic testing with peripheral stimulation produces horizontal nystagmus of appropriate direction with the targets moving to each side. The torsion swing test with the eyes closed produces normal direction-changing horizontal nystagmus. Positional head testing with the eyes closed and the patient in the head hanging, left lateral, right lateral, and sitting positions produces no nystagmus. Cold and warm water caloric testing of each ear produces horizontal nystagmus of appropriate direction.
Electronystagmography within normal limits.
ANALYSIS OF PATTERN
There is a bioccipital rhythm, which is organized, of about 8 Hz. Frontal activity is a mixture of rapid and slow activity. Bifrontal spike and slow wave activities are noted, which have been noted in previous EEGs. High voltage delta slow waves are also noted intermittently in the frontal areas. The spike activity noted does not generalize but spreads occipitally. Interictally, the EEG has some slow theta activity in the 5-6 Hz range. The spike and slow activity is not frequent but intermittently increases in frequency. Tow episodes of every 1 second, lasting 4 seconds, are recorded. Otherwise, the spike activity appears between 2 minutes to 3 minutes in the EEG. The high-frequency delta waves are not as frequent. One episode lasting up to 5 seconds is also noted. No clinical correlation was noted with this EEG by the EEG tech or by the patient. The patient is not photosensitive.
Compared to the previous EEG, it is either unchanged or slightly better.
The patient is using Advil, 3 tablets q.4-5h. She also tried Valium q.h.s., which is helpful.
PAST HISTORY: The patient has had a tonsillectomy and a tubal ligation. She has hayfever but no medication allergies. There have been no other significant prior illnesses.
SOCIAL HISTORY: Prior to the left leg problem, the patient was doing temporary office work. She now, however, is unable to work.
NEUROLOGICAL EXAMINATION: The neurological examination reveals the patient to be a well-developed, well-nourished white female. A single 1 x 2-inch cafe-au-lait spot is present over the dorsum of the left foot just proximal to the 4th and 5th toes. Bending forward with the knees extended, the patient misses her toes with her fingertips by 6 inches. Straight leg raising of the right leg is negative at 75 degrees; straight leg raising of the left leg at 75 degrees produces some discomfort only in the area of the left hip. Bent leg raising is negative. The patient complains of severe pain on compression of any part or side of the left knee.
All major muscle groups have strong symmetrical power. The patient complains of a great deal of left knee pain when she attempts to contract the extensors of the left knee strongly. There appears to be dullness to pin over the dorsum of the left large toe and over the lateral aspect of the left foot. Pin sensation is, otherwise, intact, including all of the other lumbar dermatomes. Position and vibratory sensations are normal. The deep tendon reflexes are 2+ and symmetrical. Both toes are down-going. The Romberg test is negative. There is no drift of the outstretched extremities. The pupils and fundi are normal.
Left superficial peroneal nerve: Terminal latency 3.16; NCV 47.5 mps.
Right superficial peroneal nerve: Terminal latency 3.08; NCV 47.2 mps.
Left sural nerve: Terminal latency 2.96; NCV 50.7 mps.
Right sural nerve: Terminal latency 2.94; NCV 51.0 mps.
Left peroneal nerve 46.0
Right peroneal nerve 45.8
Left tibial nerve 46.0
Right tibial nerve 46.4
Left sciatic nerve 27.7
Right sciatic nerve 28.4
The amplitudes of the motor action potentials produced by stimulating the left and right peroneal nerves are low. The amplitudes of the other motor action potentials are normal.
The most striking feature of the patient's neurological examination is the great deal of pain produced by compression or palpation of any part of the left knee. She appears to have dullness to pin over the left large toe and over the lateral aspect of the left foot.
The electromyographic study was limited by poor needle electrode tolerance. The muscles which were able to be examined, however, were normal.
The nerve conduction velocity study was mildly abnormal because of the low amplitude of the motor action potentials produced by stimulating the left and the right peroneal nerves. This was a very symmetrical finding. The rest of the nerve conduction velocity study is normal.
The etiology of the patient's left lower extremity symptoms remains unclear. Although the pin sensation findings suggest the possibility of a lumbar root problem, the finding is subjective in nature, and there are no other definite signs of nerve root injury. The pain on compression of the left knee suggests a primary knee problem.
I have administered Anaprox, 275 mg q.i.d. with food or milk. A bone scan is additionally requested. Also requested are a CBC, arthritis profile, and special chemistry profile.
Thank you very much for asking me to examine this patient.