History and Physical — Patient 49

History

Present Illness: This is the case of a 53 year old, right-handed African-American female with a three week history of weakness, pain, and tingling sensations in all four extremities. Earlier in the previous month, she had been treated at an outside hospital for an exacerbation of asthma, with two doses of intravenous steroids but no initiation of chronic oral steroid therapy. Over the next few weeks, she was treated for several more asthma exacerbations and a diarrheal illness as an out-patient by other physicians. The patient's neurologic symptoms began three weeks ago with sensory loss, paresthesias and pain in her feet. The pain was described as burning and dysesthetic in quality. These sensory symptoms rapidly progressed to involve initially her distal lower extremities, followed by her proximal lower extremities, and subsequently her upper extremities. Over the next two to three days, she developed bilateral leg weakness followed by bilateral arm weakness. By the time of the patient's presentation at an outside hospital, her weakness was sufficiently severe to preclude walking, using the bathroom without assistance, or feeding herself without assistance. She denied bowel or bladder incontinence. CSF studies and pulmonary function tests performed at the outside hospital were reportedly within normal limits at the time of admission.

The patient was transferred to the Neurology Service at The Methodist Hospital for further evaluation and management. Reportedly her neurologic symptoms had not progressed over three weeks of her hospitalization at the outside hospital, but also had not improved. At the time of transfer, the patient was lethargic, attributed by the patient to receiving pain medications including morphine. No medication records were sent with the patient at the time of hospital transfer.

Past Medical History: Asthma, never intubated or dependent on oral steroids; Peptic ulcer disease; Possible iron deficiency anemia; Possible history of thyroid disease; Sinusitis and "allergies".

Allergies: No known drug allergies.

Medications: Accolate (zafirlukast) 20 mg p.o. BID, Albuterol metered-dose-inhaler 2 puffs q4-6 hours PRN, Atrovent (ipratropium) metered-dose inhaler 2 puffs q4-6 hours PRN, Flovent (fluticasone) metered-dose inhaler 2 puffs BID, Serevent (salmeterol) metered-dose inhaler 2 puffs BID with spacer, Prilosec (omeprazole) 1 p.o. QD.

Family History: No family history of neurologic diseases, respiratory diseases, diabetes mellitus, or hypertension.

Social History: The patient works as a drug counselor. She denies any tobacco, alcohol, or drug abuse.

Physical Exam

General: The patient is lying in bed in no acute distress.

Vital Signs: Temp. 98.8 F, Blood pressure 99/59 mmHg, Pulse 119/min, Respirations 24/min, Oxygen saturation 98% on room air.

HEENT: Normocephalic, atraumatic. Sclerae anicteric. Nasopharynx and oropharynx are clear. No oral thrush present. Mucosal membranes are moist.

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

Chest: Clear to auscultation bilaterally without wheezes, rales, or rhonchi. No use of accessory muscles.

Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops.

Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds, no hepatosplenomegaly.

Extremities: Peripheral pulses intact. No cyanosis, clubbing, or edema.

Skin: No rashes or skin lesions noted.

Neurological Examination

Mental Status: Initially, the patient was sleeping, but easily arousable. She stated that she was lethargic due to excess pain medication given prior to transfer. She appeared alert and oriented to person, place, and time. She followed two step commands, but could not give very detailed answers to questions and did not complete a mental status examination. The next morning, she scored 28/28 on a Folstein Mini-Mental Status Examination (she did not attempt drawing pentagons or writing a sentence because of weakness).

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils equal and reactive to light and accommodation. Visual fields full to confrontation. Fundoscopic exam within normal limits.
III / IV / VIExtraocular movements intact.
VLight touch and pinprick intact. Muscles of mastication intact.
VIIFace symmetric with strength intact.
VIIIHearing intact to finger rub bilaterally.
IX / XSymmetric palate elevation, gag intact.
XI5/5 strength in sternocleidomastoid and trapezius.
XIITongue midline without atrophy or fibrillations.

 

Motor: Normal bulk, decreased tone in all four extremities. No fasiculations noted.

Initial exam (at night): Bilateral proximal upper extremities 3/5; bilateral distal upper extremities 2/5; bilateral proximal lower extremities 2-/5; bilateral distal lower extremities 0/5.

Exam the next morning: Deltoids 4+/5, biceps 4+/5, triceps 4+/5, brachioradialis 4-/5, wrist extensors 3/5, wrist flexors 3/5, finger extensors 1/5, finger flexors 2/5, iliopsoas right 2/5 and left 1/5, knee extensors 3/5, knee flexors 3/5, ankle dorsiflexors 0/5, ankle plantar flexors 0/5, toe extensors 0/5.

Reflexes: Absent biceps, triceps, brachioradialis, patellar, and Achilles reflexes

Sensation: Symmetric stocking pattern decrease in light touch, pinprick, vibration and proprioception in both lower extremities, to the knees; symmetric glove pattern decrease to light touch, pinprick, vibration, and proprioception, to the elbows.

Coordination: Unable to assess due to weakness.

Gait: Unable to assess due to weakness.

Hospital Course

The patient was treated in the hospital, initially with plasma exchange, but developed a fever after the first exchange leading to interruption of this treatment (the fever was later felt to result from a urinary tract infection). She received a five-day course of intravenous immune globulin (total dose 2 g/kg) with some clinical improvement beginning during her course of treatment. She also received low doses (50-100 mg) of intravenous methylprednisolone, beginning on the day of admission to our hospital, as adjuvant treatment for her neuropathic pain, which also improved. She was transferred to a comprehensive rehabilitation hospital, with slowly improving weakness. One month later, following empiric oral antibiotic treatment of a recurrent urinary tract infection, the patient developed an exacerbation of clinical weakness, together with intermittent fever (to 103 F) and a skin rash. At that time she was transferred to the Neurology Service for re-evaluation.

Physical Exam (Re-Evaluation)

Vital Signs: Temp. 98.9 F, Blood pressure 123/65 mmHg, Pulse 101/min, Respirations 20/min.

HEENT: Sclerae anicteric. Nasopharynx clear. Mucosal membranes are moist. White chalky-appearing lesions are present on the tongue. No facial rashes noted.

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

Chest: Coarse breath sounds throughout. No use of accessory muscles.

Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops.

Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds, no hepatosplenomegaly.

Extremities: Peripheral pulses intact. 1+ pedal edema, 2+ peripheral pulses, no cyanosis.

Skin: A non-blanching, erythematous macular rash with a few palpable papules is evident on the dorsum of the feet, sides of both hands, and the right hip. The rash becomes confluent underneath the patient's right breast.

Neurological Examination (Re-Evaluation)

Mental Status: Alert and oriented to person, place, time, and situation.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils equal and reactive to light and accommodation. Visual fields full to confrontation. Fundoscopic exam within normal limits.
III / IV / VIExtraocular movements intact.
VLight touch and pinprick intact. Muscles of mastication intact.
VIIFace symmetric with strength intact.
VIIIHearing intact to finger rub bilaterally.
IX / XSymmetric palate elevation, gag intact.
XI5/5 strength in sternocleidomastoid and trapezius.
XIITongue midline without atrophy or fibrillations.

 

Motor: Normal bulk, decreased tone in all four extremities. No fasciculations noted.

Strength in deltoids 4/5, biceps 4-/5, triceps 4-/5, brachioradialis 4-/5, wrist extensors 3/5, wrist flexors 3/5, finger extensors 3/5, finger flexors 3/5, Iliopsoas 3/5, knee extensors 3/5, knee flexors 3/5, ankle dorsiflexors 0/5, ankle plantar flexors 0/5, toe extensors 0/5.

Reflexes: 1+ biceps, triceps, brachioradialis bilaterally; absent patellar and Achilles reflexes.

Sensation: Symmetric stocking pattern decrease in light touch, pinprick, vibration and proprioception was evident in both lower extremities up to the knees. No sensory level was detected. Sensation was intact to all modalities in upper extremities.

Coordination: Unable to assess due to weakness.

Gait: Unable to assess due to weakness.

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