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Assessment
(Robert W Dow, MD - July 8, 1992)

BURNS, JOLYNNE

REFERRING PHYSICIANS:  Peter Morgan/Mike Smith.

07/08/92: Ms. Burns was seen for reevaluation along with her husband.  In talking with her husband, I find that they have known each other for about six years.   Since her first met her, her gait has been impaired and her really can't tell that there has been as significant difference in her ambulation other than when she was taking large doses of neuroleptics.  Her speach in the same way.  Over the past three or four years, he has noticed that her balance seems to be a little less and wonders if this is a progressice phenomenon.  This is noticeable when she arises and then simply seems to lose her balance and wave her arms about in the air.  Her handwriting has not changed fundamentally in this period of time.  In talking with her, she was an active adolescent and was a high school cheerleader capable of doing turnovers, hand-stands, etc.  She had more difficulty learning this than the other girls.   She has had difficulty in her balance her whole life.  She has always been described by her friends as having no gyro meaning gyroscope.  At age five, she fell out of the back of a pick-up truck and struck her head and was unconscious for five minutes.  There is no known abnormalities of her birth or pregnancy.  She is left handed and, of course, all of her incoordination has been attributed by her family to left handedness.

Now she is taking Haldol 1 mg at bedtime, getting along well, and in general is coming along nicely from her psychotic illness.

A complete neurologic exam shows her metal status to be normal.  Her husband notes that her memory for some events over the past several months is not like it seems like it should be, but prior events and prior to her break, she had no difficulties with thinking.  Her speech is dysarthric and he says that this is improving by the day on lower doses of medicine.  I describe her dysarthric as moderate.  Cranial nerves are normal II-XII including funduscopic and visual fields.  Motor testing shows symmetric tone and strength.  There is no drift present.  Deep tendon refexes are brisk, but the toe signs are downgoing on today's exam.  She has somewhat high arches.  Sensory examination is normal on pinprick and vibratory testing.   Coordination testing reveals mild incoordination on finger-nose-finger and heel-shin.  There is a little bit of pass pointing present.  Heel-shin maneuver is performed without ataxia.  Her gait is peculiar: stiff legged, landing on her heels with a base of anywhere from 6 to 12 inches.  She can tandem walk very slowly holding her arms wide, but this is unsteady.

I would be reluctant to make any diagnosis of a degenerative process at this point.  I think we should get her well away from the neuroleptic and reevaluate her.   Dr. Gene Matos would be available to see her in follow-up, and I think this is really a good thing because she will get a second opinion in that evaluation.  I have asked for her to come back in about two months to see Dr. Matos.

Thank you again for asking me to see this patient.

Robert Dow, M.D./fmc

DD: 07/08/92
DT: 07/10/92

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