History and Physical — Patient 47

History

Present Illness: The patient is a 43 year old, right-handed veterinarian with headaches beginning about one month prior to admission to an outside hospital. The headaches were described as bitemporal, dull, and aching in character, and were clearly worsened when the patient sat up, and improved when he lay down. Coughing or sneezing also worsened the headaches. Mild photophobia accompanied the headaches. His headaches gradually worsened in severity and frequency, and he sought medical attention. He was admitted to an outside hospital, where an MRI scan of the head was reportedly abnormal, but did not reveal a specific diagnosis. During that admission, he received parenteral analgesia and was discharged home on oral analgesics. He was admitted to the Neurology Service at the Methodist Hospital on Feb. 2, 1999 for further evaluation, with persistent headaches. At the time of this admission, a detailed general and neurological examination was essentially normal. During the patient's admission, he underwent an empiric five-day course of high-dose IV methylprednisolone (1 g/day), with dramatic improvement in his symptoms, and he was discharged home on oral predisone, tapered over three weeks. He again developed headaches, shortly after completing his taper of prednisone. He continued to work, but the headaches gradually worsened, and he was readmitted to the Methodist Hospital after six months. At this time, he had also begun to develop visual blurring in the left eye, together with right arm numbness and weakness.

Past Medical History: Three years prior to the current illness, he had three weeks of positional headache which resolved without treatment. Pars planitis of left eye in 1986, treated with steroids. Rib fractures during a fall in 1996.

Allergies: No known drug allergies.

Medications: None, although he had been given a prescription for oral morphine at the time of his assessment at the outside hospital.

Family History: His mother has coronary artery disease, and his father died from lung cancer. There is no family history of neurologic disease or malignancy.

Social History: The patient is a self-employed veterinarian working with small pets, birds, and farm animals. He does not smoke, and drinks occasionally. He has had no recent travel or significant contact with ill humans. No known history of TB exposure.

Review of Systems: No fevers, weight loss or night sweats. No palpitations, pleuritic or other chest pain, shortness of breath, exercise limitations, or cough. No gastrointestinal complaints. No history of malignancy or significant infectious diseases. No genitourinary complaints. No skin rashes or lesions, no facial erythema, and no arthralgias or limitation of joint motion. He denies depressive symptoms, neck stiffness, loss of consciousness, seizures, visual or hearing changes, weakness, sensory loss, or vertigo.

Physical Exam

General: Well-developed, well-nourished white male, appearing slightly uncomfortable but in no significant distress.

Vital Signs: Temperature 99.1 F, BP 149/89 mmHg, HR 77/min.

HEENT: No cranial abnormalities. Normal temporal pulses. Conjunctivae appear normal. Oropharynx clear, with no oral mucosal lesions noted.

Neck: Supple; No lymphadenopathy.

Chest: Normal jugular venous pulsations. Normal breath sounds to auscultation.

Cardiovascular: Regular heart rate and rhythm without murmurs or rubs.

Abdomen: Soft, without organomegaly or masses. Normal bowel sounds.

Extremities: No clubbing or edema, normal skin color without rashes, lesions. Joint examination showed full range without pain or swelling.

Neurological Examination

Mental Status: Alert and cooperative. Folstein MMSE score was 30/30.

Cranial Nerves: Visual acuity 20/20 OD, 20/100 OS (changed from 20/20 on the previous evaluation). Intact visual fields to confrontation. Pupils 4 mm, with a mild afferent pupillary defect on the left (changed from a previously normal evaluation). Funduscopy at the bedside was normal. Extraocular movements full in all directions of gaze. Normal facial sensation and muscles of mastication. Normal facial expressions, symmetry, strength of lip and eye closure, and speech. Hearing was intact to finger rubbing and tuning fork assessment. Palate was midline with a normal gag. Sternocleidomastoid strength was intact bilaterally. Tongue was midline, with normal bulk.

Motor: Normal tone, with MRC grade 5/5 strength in all major muscle groups of the left, but 4/5 in the right deltoid and 4+/5 in the right biceps and brachioradialis. The remainder of the motor exam of the right side showed normal (grade 5/5) strength.

Reflexes: Tendon reflexes were 2/4 in arms and at the knees, and 1/4 at the ankles. No clonus was detected. Plantar responses were flexor. No pathologic reflexes were noted.

Sensation: Intact to touch, pinprick, temperature, and proprioception in all extremities.

Cerebellar: Normal, with no ataxia, dysmetria, or dysdiadochokinesis.

Gait: Normal, including tandem walking.

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