History and Physical — Patient 23

History

The patient is a 61 year old right-handed white male who, while watching television, developed the sudden onset of blurred vision in his upper right visual field. This problem persisted even after alternately closing the right and left eyes. While continuing to watch television, he also noted difficulty reading captions presented on the screen. He was able to read the captions only by sounding out each individual letter. Reading the word as a whole was impossible for him, but if he spelled the word aloud he could make sense of it. He could understand and could produce speech without any difficulty. Later, while discussing his new problems with his wife, he discovered that he could not perform calculations in his head—a task that, as an accountant, he could perform easily before. He denied weakness, numbness, tingling, diplopia, dysarthria, dysphagia, dizziness, vertigo, or word-finding difficulty. He denied any previous difficulty with language and was previously an avid reader. When he arrived at the hospital, one day after the onset of his symptoms, the visual deficit was improving but his reading problems persisted.

Past Medical History: Coronary artery disease.

Past Surgical History: CABG, 1992; Aortic valve replacement (St. Jude's valve), 1992.

Allergies: No known drug allergies.

Medications: Coumadin 6mg qd.

Physical Exam

General: The patient is a well-developed, well-nourished, well-kept male appearing his stated age.

Vital Signs: B.P. 146/72; pulse 84; temperature 99.0 F; respirations 18.

HEENT: Normocephalic, atraumatic; sclerae are anicteric, conjunctivae are pink; oropharynx is moist without lesions. Neck is supple without bruits.

Chest: Lungs are clear to auscultation and percussion bilaterally; respiratory excursion is normal.

Cardiovascular: Regular rate and rhythm without rubs, gallops, or murmurs; normal S1, mechanical click S2.

Abdomen: Soft, nontender with normal bowel sounds and no bruits. No hepatosplenomegaly.

Extremities: No cyanosis, clubbing, or edema.

Skin: No significant hypo- or hyper-pigmented lesions.

Neurological Examination

Mental Status:

Area

Findings

AttentionIntact.
LanguageIntact fluency, comprehension, repetition, naming, and writing. Reading is markedly affected. When asked to read a word or phrase ("bookstore"), he could not read the word "as a whole". He would pronounce each letter individually to spell the word to himself ("b-o-o-k-s-t-o-r-e") and, thus, grasp its meaning. He had no difficulty writing full sentences with correct syntax, both spontaneously and to dictation. However, when asked to read the sentence he had written, he was unable to do so without spelling each letter individually.
MemoryIntact long and short-term memory for verbal and non-linguistic visual information.
Constructional AbilityIntact.
Abstract ThinkingNormal.
CalculationsHe demonstrated marked difficulty with calculations and could not reliably subtract two 3-digit numbers.
PraxisThere was no evidence of ideomotor or ideational apraxias.
Other Higher Cortical FunctionsThe patient did not evidence right-left confusion, finger agnosia, achromatopsia, optic ataxia, simultagnosia, or other visual agnosia.

 

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIVisual acuity is 20/20 OU; pupils are 3mm and reactive to light and accomodation bilaterally; visual field exam shows a right superior quadrantanopsia.
III / IV / VIExtraocular movements are intact without nystagmus or ptosis.
VSensation to light touch and pinprick in all three divisions bilaterally; corneal responses intact bilaterally; muscles of mastication show normal strength.
VIISmile is symmetrical.
VIIIIntact to bilateral finger rub.
IX / XPalate and uvula rise symmetrically; gag is intact bilaterally.
XISternocleidomastoid and trapezius strength intact bilaterally.
XIITongue is midline without atrophy or fibrillations.

 

Motor: Tone was normal. Muscle bulk was normal. There was no cogwheel rigidity or tremor. Bilateral strength testing of both the upper and lower extremities was 5.

Reflexes: Bilateral 2+ for upper and lower extremities. Hoffman's and Babinski signs were absent bilaterally. There was no jaw jerk.

Sensation: Intact throughout to light touch, pinprick, temperature sense, vibration, and proprioception. Romberg was negative. Graphaesthesia and stereognosis were intact bilaterally. Double simultaneous stimulation produced no extinction on either side.

Cerebellar: Intact finger-nose-finger, heel-shin, and rapid alternating movements. There was no loss of check.

Gait: Normal stance, stride, arm swing, pivot. Toe-walking, heel-walking, and tandem gait were normal.

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