History and Physical — Patient 36
Present Illness: Patient #36 is a 44 year old right handed white male dental assistant with a prior history of chronic hepatitis C infection diagnosed one year prior to presentation. He was recently admitted after a two week history of nausea, vomiting, diarrhea, and fever, and treated with intravenous hydration and an oral quinolone antibiotic.
On the day prior to admission, the patient noticed lower extremity weakness with inability to lift his feet (right greater than left), which resulted in falling while ambulating at home. This was associated with numbness and tingling in his extremities, noticeable problems with erection, and numbness in his perineal region. On the night of admission, the patient noticed right arm weakness when trying to lift his forearm and shoulder, and inability to grip with his hand or extend his fingers.
He had normal bowel and bladder function and denied back or neck pain. He had no dysarthria, dysphagia, or diplopia.
Past Medical History: Chronic viral hepatitis type C; hypertension.
Past Surgical History: None.
Medications: Lisinopril 10 mg q.d.; Nasprosyn 250 mg p.r.n; Triamcinolone cream 1% p.r.n.
Social History: Married, no children: no tobacco, ethanol, or illicit drug use.
General: Thin, white male sitting in wheelchair. No acute distress.
Vital Signs: B.P. 142/88; pulse 119; temperature 100.6 F; respiration 16.
HEENT: Atraumatic, normocephalic. Oropharynx clear, neck supple. Tympanic membranes clear with normal light reflex.
Chest: Clear to auscultation bilaterally.
Cardiovascular: S1, S2 present with normal rhythm.
Abdomen: Bowel sounds present. Mild tenderness in right upper quandrant to palpation. Liver span 16 cm. Spleen not palpable. Fluid wave not detected.
Musculoskeletal: No bony abnormalities. No joint effusions, erythema.
Skin: No skin lesions. Normal skin tone.
Genitourinary: No scrotal edema. Anal wink present with normal rectal tone.
Mental Status: Awake and alert. MMSE 30/30.
|II / III / IV / VI||EOMI, PERRLA, Visual fields intact, visual acuity 20/40 bilaterally.|
|V||Normal facial sensation to pin prick, light touch, temperature. Corneals present bilaterally. Normal strength of muscles of mastication.|
|VII||Normal facial symmety and strength; taste normal.|
|IX / X||Gag present.|
|XII||Tongue midline bilaterally.|
Reflexes: Biceps 0/4 bilaterally; brachioradialis 0/4 bilaterally; triceps 1+/4; knees 2/4; Achilles 0/4 bilaterally.
Sensation: Diffuse loss to both arms and legs in a glove/stocking distribution, affecting pinprick and temperature more than position sense and vibration. No sensory level was detected.
Gait: Unable to assess.