History and Physical — Patient 48

History

Present Illness: The patient is a 23 year old black female presenting to the emergency room with anosmia, visual disturbances, facial numbness and increasing headaches of about six months' duration. She states that her first symptom was difficulty in perceiving odors, noted to occur abruptly about six months ago. She works as a nanny, and noted that she could no longer discern by smell when an infant needed a diaper change, or distinguish among certain solvents and perfumes. More recently, she has been noticing changes in the taste of foods. She has had easily controlled, migraine-type headaches since childhood, which have changed in nature, frequency and severity over the past six months. She describes predominantly left-sided headaches without aura, which have now become increasingly intense, with throbbing pain extending to the right forehead, and occasional severe nausea and vomiting early in the course of the headache. About four weeks prior to admission, the patient began to experience numbness of her cheek and chin on the left side, such that she bit her cheek often while eating. Unassociated with the headaches, the patient has also experienced episodes of abrupt, transient loss of vision (described as blurring) in the right eye, without pain. For the last few days, she has noted that these visual disturbances have been accompanied by double vision, occurring several times per day, with images side by side in the horizontal plane, and most evident when she looks to the right. Due to the progression of these symptoms, the patient was brought to the emergency room at the Ben Taub General Hospital by her husband, and admitted for further evaluation.

Past Medical History: Anemia of unknown cause, with extensive evaluation including an unrevealing bone marrow biopsy at an outside facility; Sickle cell trait; Left-sided ear infection three months ago, treated initially with eardrops and oral antibiotics, but which caused left sided facial swelling and required typanostomy drainage before resolution.

Past Surgical History: None.

Allergies: No known drug allergies.

Medications: Ferrous sulfate 325 mg p.o. daily.

Family History: Hypertension and diabetes in the patient's father. Her mother suffered from an unexplained "coma" with spontaneous resolution after nine months. Otherwise, the family history is non-contributory.

Social History: Negative for tobacco, alcohol or illicit drug use. The patient is a high school graduate and works as a nanny. She has been married for three years. There is a remote history of assault, and subsequent treatment for herpes simplex and for papillomas.

Review of Systems: No history of head trauma or bone fractures. The patient has recently recovered from an extended illness diagnosed as pneumonia, during which she lost nearly 100 pounds, requiring bronchoscopy but not mechanical ventilation, and treated with antibiotics (records not available). She experienced transient chest pain during this illness, but otherwise has no history of heart disease, syncope, murmurs, edema, orthopnea, or paroxysmal nocturnal dyspnea. She has had no gastrointestinal or urinary tract symptoms. She recently had a non-pruritic rash on her legs that disappeared after using Cort-Aid cream topically for a week or two. As mentioned previously, there is a history of childhood migraine. She has also had occasional knee discomfort, attributed to overuse, and responsive to over-the-counter medications. There is no history of significant fatigue, fevers, chills, or night sweats.

Physical Exam

General: Appears comfortable and interactive during the examination, but gives a somewhat vague history; part of the history is obtained from her husband.

Vital Signs: Temperature 97.9 F, blood pressure 120/79 mmHg, pulse 83/min, respirations 18/min.

HEENT: Normocephalic without evidence of trauma, anicteric sclerae, mucous membranes moist without erythema or exudates. Fundoscopic examination reveals bilateral disc edema, right greater than left. There is no evidence of perivascular cuffing, hemorrhages or exudates on retinal examination.

Neck: Supple without jugular venous distention or lymphadenopathy. No carotid bruits were heard.

Chest: Clear to auscultation bilaterally.

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

Abdomen: Normoactive bowel sounds, nontender, nondistended. No palpable organomegaly.

Extremities: No cyanosis, clubbing or edema. No joint swelling, pain, or limitation of motion.

Skin: Warm and dry with no lesions or rashes.

Neurological Examination

Mental Status: Mental Status: Alert and oriented to person, place, and time; speech fluent with normal comprehension and repetition. Intact immediate verbal recall (3/3) and 2/3 delayed recall, without prompting. Psychomotor responses are minimally slowed. Praxis, naming, writing, directed attention, visual recognition, and speech prosody appear intact.

Cranial Nerves: Cannot identify multiple odorants on a sniff test

Cranial Nerves

Findings

INot tested.
IIVisual fields intact to confrontation. Near visual acuity 20/40 bilaterally, correcting to 20/25. Pupils equally round and reactive to light;
III / IV / VIMild limitation of eye abduction on both sides, more prominent on the right. Extraocular movements in vertical planes appears intact. The patient reports blurred vision in the right eye with right lateral gaze, which reproduces her stated complaints.
VDecreased sensation in the second and third divisions of the trigeminal nerve on the left, to all modalities;
VIIIntact facial strength and symmetry.
VIIIIntact hearing to finger rubbing, without lateralization on the Weber test.
IX / XIntact palatal elevation.
XIIntact trapezius and sternocleidomastoid strength bilaterally;
XIIMidline tongue protrusion; no atrophy or fibrillations evident.

 

Motor: Strength 4+/5 in both upper extremities, without fully sustained effort; 5/5 in both lower extremities. Normal muscle tone and bulk throughout.

Reflexes: 2/4 and symmetric throughout. No pathologic reflexes noted.

Sensation: Intact to all modalities in both upper and lower extremities.

Cerebellar: Finger-to-nose, heel-to-shin and rapid alternating movements intact.

Gait: Able to heel and toe walk. Steps off initially with tandem walking.

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