History and Physical — Patient 43

History

Present Illness: The patient is a 65 year old, previously healthy white male, who presented to the Michael E. DeBakey Veterans Affairs Medical Center with a three-day history of progressive left upper extremity weakness. He first noticed symptoms while trying to type using his left hand. His weakness progressed over the next 48 hours prior to admission, but did not spread to involve the face or lower extremity. He denied any weakness or numbness, headache, nausea, vomiting, weight loss, seizures, fever, or chills. The patient had no history suggestive of previous strokes or transient ischemic attacks, and denied any history of hypertension, diabetes mellitus, or cardiac disease. However, he is a chronic smoker, and there is a family history of cardiovascular disease. He has no history of hematuria, gastrointestinal bleeding, or epistaxis.

Past Medical History: Previously healthy, with no significant medical illnesses or surgeries. The patient had a remote history of ethanol abuse, but stopped drinking alcohol in 1990. As previously mentioned, there is a long history of tobacco use (more than 40 years, 2-3 packs per day).

Medications: None.

Family History: The patient's mother had hypertension, and his father had coronary artery disease, and died from a presumed "heart attack." No other family history is available as the patient is not in contact with many of his family members.

Social History: He is a retired construction worker, who traveled with his construction company and worked in several countries including India, Iran, the Philippines, and Mexico. He has been in the United States for the last 10 years, but has traveled recently to Mexico. He denies any illicit drug abuse, or any extramarital sexual contact.

Physical Exam

General: Well-developed, well nourished, pleasant gentleman in no acute distress, favoring his left upper extremity.

Vital Signs: B.P. 132/84; pulse 76; temperature 97.8 F; respiration 12.

HEENT: Atraumatic, normocephalic. No oral or nasal lesions seen.

Neck: Supple with no lymphadenopathy or evidence of jugular venous distension.

Chest: Clear to auscultation bilaterally, no evidence of crackles.

Cardiovascular: Regular rate and rhythm, no murmurs heard.

Abdomen: Soft, non-tender, non-distended, bowel sounds present. Stool guaiac negative.

Extremities: No evidence of cyanosis, clubbing or edema.

Skin: No rashes or lesions.

Neurological Examination

Mental Status: Alert, with appropriate affect. Score 28/30 on the Mini-Mental Status Examination (-1 for the date and -1 for delayed recall). Speech was intact with no evidence of dysarthria or aphasia. No evidence for unilateral neglect or motor intention disturbance was found.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils 3 mm, symmetrically reactive to light. Fundoscopy within normal limits with sharp disc margins, no evidence of retinal hemorrhages or exudates.
III / IV / VIIntact extraocular motility, no nystagmus.
VIntact sensation over V1, V2, and V3 distributions. Normal strength of mastication muscles bilaterally. Examination of corneal reflex was deferred.
VIISymmetric face, with no evidence of any facial weakness.
VIIIIntact hearing to finger rubbing and tuning fork tests (Weber, Rinne) bilaterally.
IX / XSymmetric elevation of the palate. Uvula midline, intact palatal and pharyngeal reflexes bilaterally.
XIIIntact sternocleidomastoid and trapezius muscle strength bilaterally.

 

Motor: Moderately decreased tone in the left upper extremity.

Strength

Right

Left

Upper Extremities

  
Deltoid4+2+
Biceps5-3-
Triceps5-3-
Brachioradialis5-3-
Wrist Extensors4+2
Wrist Flexors5-2+
Finger Extensors4+2
Finger Flexors5-2+

Lower Extremities

  
Intrinsics4+2
Iliopsoas4+4
Quadriceps54+
Hamstrings5-4+
Ankle Dorsiflexors5+4
Ankle Plantarflexors54+
Extensor Hallucis Longus5-4

 

Reflexes: 2+ in right triceps, biceps and brachioradialis, 1+ in left triceps and biceps, with absent left brachioradialis tendon reflex. 2+ patellar reflexes and absent ankle tendon reflexes bilaterally. Plantar responses were extensor on the left, and equivocal on the right.

Sensation: Diminished sensation to pinprick, light-touch, and vibration was noted over the entire left upper extremity.

Cerebellar: Intact finger to nose testing in the right upper extremity. The left upper extremity was not tested due to weakness.

Gait: A mild hemiparetic gait was noted on the left side; the patient was able to tandem walk and toe-walk, but could not walk on his heels.

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