History and Physical — Patient 35

History

Present Illness: This patient is a 69-year-old, right-handed male with a five year history of memory loss and speech dysfunction. He was recently evaluated by his primary care physician and started on anticholinesterase therapy with donepezil and antidepressant therapy with sertraline. In the last three months, he had developed a resting tremor, and was referred to the Neurology Service for evaluation. His previous history indicated a five-year history of word-finding problems, and progressive impairment of verbal expression. At present, he cannot recall the name of his significant other. He has noted other functional impairments including inability to handle his checkbook, or even to do basic arithmetic. He says that he can no longer play golf due to problems with tremor and poor coordination. He can sign his name, and write a few simple words, but he no longer reads. He rapidly forgets the names of people, names of items, dates, and amounts of money. He denies trouble with routes to places, misplacements, spatial and temporal disorientation, or forgetting procedures. He has not been observed to be impulsive, but his wife reports some emotional lability and increased frustration over his difficulty with communication. He acknowledged problems with a depressed and anxious mood, but denied vegetative symptoms of depression. He reports no problems with basic activities of daily living (grooming, dressing, etc.). He continues to drive in his local area. Review of systems is negative for nausea, vomiting, anorexia or weight loss. He denied problems with balance, or weakness/numbness of the right side of his body.

Past Medical History: Positive for hypertension (treated), angina and arthritis. There is no history of diabetes, or CVA.

Past Surgical History: Cholecystectomy, right eyelid surgery.

Allergies: No known drug allergies.

Medications: ECASA 325 mg p.o. QD, Sertraline 50 mg p.o. QD, Verapamil 180 mg SA QD, NTG 0.4 mg SL PRN, Tylenol PRN.

Family History: Positive for cardiac disease in his father who died at age 75. No history of speech impairment or progressive dementia in the family. No other known neurologic conditions.

Social History: He is divorced, and resides with a female companion in a trailer home. He was educated through the seventh grade and was employed as a machinist prior to his retirement. No children. No history of alcohol or drug abuse. He did smoke cigarettes (one pack per day), but quit six years ago.

Physical Exam

General: Pleasant, ambulatory, and in no acute distress. Expressive speech shows decreased phrase length, dysnomia, and semantic paraphasias and word substitutions.

Vital Signs: B.P. 155/73; pulse 63; temperature 98.8 F; respiration 20.

HEENT: Normocephalic, no carotid bruits.

Chest: Lung fields clear to auscultation, no wheeze or rhonchi.

Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallop.

Abdomen: Normal bowel sounds. Soft, non-tender, not distended.

Extremities: No cyanosis, clubbing, or edema.

Skin: No lesions, hypo- or hyperpigmented areas.

Neurological Examination

Mental Status: The patient was alert and aware of his environment. He was oriented to place, person, and exact day, and date. He was cooperative, well groomed and friendly. His mood was pleasant, mildly anxious, and his affect appropriate. As noted above, his speech was marked by word finding problems, blocking, and semantic and phonemic paraphasias. He could follow simple commands, but had difficulty with multiple steps. Repetition was impaired. There was no gross right-left confusion. Visual attention was grossly intact without distractibility. Drawings (circle, cube, clock, and intersecting pentagons) showed some impairment of higher-order visual-spatial and integrative functions. There were deficits in fine motor programming, but no ideomotor or ideational apraxia. On mental status testing, he could not spell forward or backward, and had difficulty with basic addition and subtraction. Reading was limited to gist perception of simple phrases. He could write and name, and digits 1 to 9. He recalled none of three items after a short delay. His overall mini-mental status score was 13/30.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIFundi benign without papilledema, visual fields intact to confrontation.
III / IV / VIExtraocular movements intact without nystagmus, disconjugate gaze or ptosis.
VNormal facial sensation V1, V2, V3.
VIINormal facial symmetry.
VIIIHearing intact to finger rub bilaterally.
IX / XPalate and uvula in midline.
XINormal SCM power.
XIITongue protrudes in midline.

 

Motor: Normal tone and bulk. Mild resting tremor in upper extremities, more on the left than right, but no cogwheel rigidity. Mild facilitatory paratonia bilaterally. Power was 5/5 in upper and lower extremities symmetrically.

Reflexes: 2+ and symmetrical throughout.

Sensation: Normal exam to light tough, pinprick, vibration and position sense. Romberg was negative.

Cerebellar: Mild tremor on finger-to-nose, but no dysmetria. Normal heel-to-shin, and rapid-alternating movements; no ocular dysmetria.

Gait: Intact for heel, toe, and tandem walk. Normal quick turn.

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