History and Physical — Patient 31

History

Present Illness: Patient #31 is a 59 year old right-handed African-American male with a long history of hypertension and adult onset diabetes mellitus who presented to the VAMC emergency room complaining of loss of vision in both eyes. Over the five days prior to his arrival in the E.R., he complained of a vague bifrontal headache; and on the day of admission, he noted blurred and double vision. He was unable to better describe the diplopia (could not qualify it as vertical or horizontal in character). During that day he began to walk into walls and was unable to drive. His wife noticed him to be confused and inattentive for brief periods of time. He next noticed that he could see only the left half of a drinking glass, but this problem resolved within two minutes. Two hours before presentation he began to see fleeting blue and red lights, followed by a gradual loss of vision in both eyes over the next hour. During this time, his wife noticed that his alertness fluctuated and that his "eyes jumped around".

He denied any recent infections, fever, chills, shortness of breath, or palpitations. He denied eye pain, dysphagia, dysarthria, vertigo, loss of consciousness, weakness, or numbness. He also denied any abnormalities in bowel or bladder function.

Past Medical History: Moderately well-controlled type 2 diabetes mellitus and hypertension diagnosed eight weeks previously. He had a history of a single TIA six years ago, characterized by transient weakness and numbness on the left half of his body that resolved in 12 hours.

Past Surgical History: None.

Allergies: No known drug allergies.

Medications: Glucophage 500 mg BID, Prinivil 20 mg QD, Glipizide 10 mg BID. Indapamide 2.5 mg QD.

Family History: Both parents had adult onset diabetes mellitus. There is no family history of neurological disorders.

Social History: The patient is a manual laborer who lives with his wife. He smokes one pack of cigarettes a day (>20 years). He does not drink alcohol. He recalled smoking cocaine two years ago, but has not done so recently.

Physical Exam

General: Well-developed, well-nourished male who was cooperative, but somewhat restless and frustrated with the examination.

Vital Signs: B.P. 148/106; pulse 97, regular; temperature 97 F; respiration 18.

HEENT: NCAT, sclerae anicteric, conjunctivae pink; oropharynx clear, moist, without lesions; neck supple without LAD, TMG, masses, or bruits.

Chest: Clear to auscultation and percussion bilaterally.

Cardiovascular: Regular rate and rhythm without rubs, gallops, or murmurs.

Abdomen: Soft, nontender, nondistended, bowel sounds intact.

Extremities: No cyanosis, clubbing, or edema.

Skin: No significant lesions.

Neurological Examination

Mental Status: Awake, alert and oriented to person, place, year, and day of the week, but not to the date or month; MMSE was 26/28 (copying, reading could not be tested as the patient could not see). Language testing was normal in terms of fluency, comprehension, repetition, and articulation.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIMinimal light perception bilaterally; unable to perceive hand movements or colors; fundoscopic exam was normal.
III / IV / VIPupils 3-4 mm, bilaterally and reactive to light (sluggishly); extraocular movements were full in all directions of gaze voluntarily; during the exam the patient experienced three episodes, lasting 10 seconds each, where his eyes moved conjugately downwards and laterally to the right associated with a few vertical down-beating nystagmoid jerks.
VSensation intact in all three divisions bilaterally; masseter and temporalis strength intact.
VIISmile is symmetrical; corneal reflex intact bilaterally.
VIIIHearing intact to bilateral finger rub.
IX / XGag intact bilaterally.
XISCM and trapezius strength intact bilaterally.
XIITongue midline without atrophy

 

Motor: Tone was normal. Muscle bulk was normal. There was no cogwheel rigidity or tremor.

Strength

Right

Left

Upper Extremities

  
Deltoid55
Biceps55
Triceps55
Wrist Extensors55
Wrist Flexors55
Finger Extensors55
Finger Flexors55

Lower Extremities

  
Iliopsoas55
Knee Extensors55
Knee Flexors55
Ankle Extensors55
Ankle Flexors55

 

Reflexes:

Reflex

Right

Left

Biceps2+2+
Triceps2+2+
Brachioradialis 2+2+
Patellar2+2+
Ankle 2+2+

 

Sensation: Intact light touch, pain, vibration, and temperature; the patient made a few subtle mistakes in proprioception testing of the distal joints of the toes bilaterally.

Cerebellar: Intact f-n-f; normal heel-shin.

Gait: Within normal limits.

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