History and Physical — Patient 29

History

Patient #29 is a 60 year old Hispanic female with a recent diagnosis of Rheumatoid Arthritis, brought to this tertiary care referral center by her daughters who reported a two month history of worsening cognitive difficulty and decreased arousal since the patient fell from a chair.

Two and a half years ago the patient began to lose weight. She initially experienced a rapid loss of weight from 160 to 130 pounds, but has continued to lose weight to the point where she now weighs 116 pounds. About nine months ago, her daughters noticed a raised bilateral rash on her feet and lower extremities with residual hyperpigmentation of her feet and the distal portion of her legs. Six months prior to her current presentation, she developed joint pains and subcutaneous nodules. Diagnostic evaluation at that time revealed a Rheumatoid Factor titer of 1:1260 and an ANA of 1:160, homogeneous pattern with an elevated ESR. She was diagnosed with Rheumatoid Arthritis and has since been treated with regimens of non-steroidal medications and immunosuppresive therapy. At the time of evaluation her current regimen was Plaquenil and Prednisone.

Four months earlier she was noted by her rheumatologist to experience gait difficulties with "falling episodes". During this time, she is also noted to have occasional fever and chills. A diagnosis of Diabetes Mellitus was presumed secondary to steroid therapy. A remote reference to a diagnosis of Felty's is also mentioned in progress notes reviewed during this time frame. Two months prior to presentation, she fell from a chair and has had rapid progressive decline in mental status since that time.

The family denies prior significant illnesses or disease.

Past Medical History: Diet-controlled hyercholesterolemia; Family members deny prior diabetes, hypertension, seizure disorder, autoimmune disease or neurological disease.

Past Surgical History: Hysterectomy in 1986 and a hernia repair in 1992.

Allergies: No known drug allergies.

Medications: Prednisone 5 mg a day, Plaquenil 200 mg a day, Reglan, Ritalin, Paxil, and Premarin.

Family History: Positive for diabetes mellitus-type II in one son and a history of joint pains in one of the daughters; her ex-husband is deceased secondary to gastric cancer.

Social History: The patient lived alone in Corpus Christi, Texas until the onset of this illness. She had been divorced for 30 years with two adult daughters and two adult sons. She does not smoke or consume alcoholic beverages.

Physical Exam

General: This is a thin Hispanic female lying in bed without signs of respiratory compromise or signs of pain or discomfort. She is intermittently responsive to verbal stimuli.

Vital Signs: B.P. 150/100 ; pulse 78 ; temperature 98.2 ; respirations were regular at 20.

HEENT: HEENT exam reveals anicteric sclera with no conjunctival erythema. There are no oral mucosal lesions and the oropharynx is clear noting a palatine torus. The neck examination shows no JVD, no bruits, and no lymphadenopathy or thyromegaly.

Chest: Exam reveals lung fields are clear to auscultation.

Cardiovascular: Exam reveals a regular rhythm with normal rate and good S1 and S2. There is no significant murmur and no rub.

Abdomen: Soft, non tender with bowel sounds present in all four quadrants; there is no evidence of hepatosplenomegaly; there is a PEG in place which is clean, dry and without evidence of induration, erythema, or exudate.

Extremities: No signs of clubbing, cyanosis, or edema.

Skin: Examination reveals hyperpigmentation on the distal extremities and small subcutaneous nodules on the extensor surfaces of the forearms.

Neurological Examination

Mental Status: Attention: intermittently alert and responsive to verbal stimuli; she was not oriented to place or time; speech is whispered, sparse, and slow; spontaneous speech is limited; comprehends simple commands but not complex commands, she could perform simple repeats; a full MMSE score was not available but she was reported to be unable to perform memory operations, write a sentence, perform constructional tasks, and did not name objects. She had evidence of ideomotor apraxias.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils were 3mm equal and reactive to light and accommodation; visual fields could not be tested reliably; disc margins were sharp.
III / IV / VIExtra-ocular movements were full by doll's testing; gaza was congugate; there was no ptosis.
VCorneal reflex was present bilaterally and sensation was intact to light touch and pin prick.
VIIFacial symmetry was noted with no signs of weakness.
VIIIHearing grossly intact.
IX / XGag reflex was present with symmetric palatal elevation.
XINo asymmetry of sternocleidomastoid or trapezius was noted but patient was not compliant for strength testing.
XIINo tongue abnormalities were noted - specifically there were no fibrillations, no atrophy or deviations noted.

 

Motor: Tone was moderately increased in both lower extremities and increased in the upper extremities with tone in the left arm markedly increased. Muscle bulk revealed moderate atrophy of all extremity muscles with wasting of the small intrinsics of the hand.

Strength

Right

Left

Upper Extremities

  
DeltoidNTNT
Biceps33-
Triceps32+
Wrist Extensors33-
Wrist FlexorsNTNT
Finger Extensors33
Finger FlexorsNTNT
Hand IntrinsicsNTNT

Lower Extremities

  
Iliopsoas32
Knee Extensors32
Knee Flexors32
Ankle Extensors32
Ankle Flexors32

 

Reflexes: Brisk on the right and there was a mild jaw jerk. Toes were downgoing on the right but upgoing on the left with Babinski examination. There was a bilateral palmomental reflex and a snout reflex but no evidence of glabellar or rooting reflex.

Reflex

Right

Left

Biceps3+1+
Triceps3+1+
Brachioradialis 3+1+
Patellar3+3+
Ankle 3+2+

 

Sensation: Revealed withdrawal of all four extremities to noxious stimuli.

Cerebellar: Not tested.

Gait: Not performed.

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