History and Physical — Patient 11

History

Patient #11 is a 75 year old Caucasian male who was referred to the Department of Neurology for memory loss, behavioral problems, and difficulty walking.

The family reported that the patient was normal until about three months ago when he began to have difficulty with driving, and lost interest in his work. He also had trouble recalling where he placed things, and subsequently in remembering people's names. The patient progressively became less communicative, and finally could not understand what other people were saying.

He then began to have problems walking, which progressed so rapidly that he was wheelchair bound by the time of referral. The patient had complained of back pain about two months prior to the referral, and was reportedly seen by a family physician who scheduled a prostate biopsy due to a high PSA. However, the procedure was cancelled because the patient had the "flu".

The family also described the patient as having problems with bowel and bladder control for the last 3-4 weeks. The wife stated that the patient made no effort to go to the bathroom, and would defecate and urinate in the bed. He was noted to perform repetitive actions; such as picking at things, scratching, and wiping his nose.

The patient was recently admitted to another hospital for thrombophlebitis of his legs, and at that time was started on medication for "depression". A CT scan of the head was performed, and the family was told that it was normal. There was no history of falls or head trauma. On questioning, the patient appeared to have a history of visual hallucinations.

Past Surgical History: Septoplasty, hernia repair, blepharoplasty for drooping eyelids.

Family History: The patient's mother died of respiratory complications but had a type of mental illness for five years prior to her death. His father committed suicide at age 23. One sister died of breast cancer.

Social History: There was no history of smoking or alcohol abuse. The patient did, however, have a history of eating cow brains about 10 years ago.

Physical Exam

Vital Signs: Temp 98.2 F, Pulse 88, BP 134/76

The patient was sitting in a wheelchair in no acute distress. He had a disheveled appearance and a slightly masked facies. The neck was supple and there was no thyromegaly or carotid bruits. The chest was clear to auscultation and heart sounds were normal. There was 2+ pitting edema in the legs with petechiae bilaterally.

Neurological Examination

Mental Status: The patient was awake, alert, and responsive. MMS was 12/30. He did not know the month, city, county, or place. He was unable to recall three objects, spell "world" backwards, draw, or follow a three step command, and refused to write.

Cranial Nerves:

Cranial Nerves

Findings

INot tested
IIUnable to assess visual fields or perform fundus exam as the patient was uncooperative. Pupils were 3 mm bilaterally and reactive.
III / IV / VIPatient followed a finger in all directions of gaze. There was slight gaze evoked nystagmus.
VDifficult to test. However, patient responded equally to pinprick on both sides of the face. Corneal reflex was symmetrical.
VII - XIAppeared to be symmetrical. Gag appeared to be normal.
XIINormal bulk of the tongue, and it was midline. No fibrillations.

 

Motor: Motor: Normal bulk, but the tone appeared to be increased. Muscle strength was difficult to assess as the patient was uncooperative. Muscle strength appeared to be in the 4/5 range in the upper extremities in almost all muscle groups. Strength in the lower extremities was not assessed due to poor cooperation. However, he was only able to stand with support on both sides.

Reflexes: Reflexes: Reflexes were symmetrical in the upper and lower extremities and were 3+/4 in the biceps, triceps, brachioradialis and knees. Ankle reflexes could not be assessed. Planter reflexes were downgoing bilaterally. There was no clonus.

The patient had a positive glabella sign, positive palmomental bilaterally, and a positive snout. There was no evidence of startle myoclonus.

Sensation: The patient responded equally to painful stimuli in all 4 extremities.

Cerebellar: There was slight dysmetria bilaterally in the upper extremities when the patient reached for objects. No titubations were noted.

Gait: Gait was extremely unsteady. The patient could stand only with support on both sides and took only two steps with great difficulty. Romberg could not be tested.

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