History and Physical — Patient 36

History

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.

Physical Exam

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.

Neurological Examination

Mental Status: Awake and alert. MMSE 30/30.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
II / III / IV / VIEOMI, PERRLA, Visual fields intact, visual acuity 20/40 bilaterally.
VNormal facial sensation to pin prick, light touch, temperature. Corneals present bilaterally. Normal strength of muscles of mastication.
VIINormal facial symmety and strength; taste normal.
VIIIIntact.
IX / XGag present.
XIIntact.
XIITongue midline bilaterally.

 

Motor:

Strength

Right

Left

Upper Extremities

  
Deltoid34
Biceps44
Triceps44
Wrist Extensors3
Wrist Flexors23
Finger Extensors3
Finger Flexors34

Lower Extremities

  
Intrinsics3
Iliopsoas44
Knee Extensors44
Knee Flexors44
Ankle Dorsiflexors3
Ankle Plantarflexors44

 

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.

Cerebellar: Intact.

Gait: Unable to assess.

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