History and Physical — Patient 52

History

Present Illness: A 53 year old, left handed Caucasian male was evaluated on the Neurology Service at The Methodist Hospital for 1 1/2 years of progressive memory problems and language disturbance. Two years prior to his evaluation, he had retired from his job installing phones, in order to spend more time with his family. There were reportedly no problems with his job performance prior to retirement. Shortly thereafter, his wife noticed that he repeatedly asked the same questions, and easily forgot recent events. Over the next few months, he also began to experience difficulties with word finding and spelling. He occasionally would substitute incorrect words in conversation, but did not have apparent difficulties with comprehension of written or spoken language. Six months prior to his presentation, he developed increasing difficulty with driving. Although he denied ever getting lost, his wife reported that he would frequently turn left instead of right, in areas that he had known for years. He admitted that it took him longer to get to his intended destinations, and that he really needed to concentrate on where he was going. He did not feel that he was getting particularly worse or better since the onset of his difficulties. In contrast, other family members and friends, as well as the patient's wife, had noted increasing forgetfulness. They also felt that he had become more irritable, more easily agitated and withdrawn since his retirement. There were no inappropriate crying or laughing spells. The patient and family denied depressed mood, significant medical illnesses, head trauma, recent chemical or toxin exposure, or significant social stresses. He did complain of intermittent feelings of shakiness or tremulousness. One month previously, he had sought medical attention for his difficulties, with reportedly nondiagnostic studies.

Past Medical History: Hospitalized at age 16 for DDT exposure (inhalation of crop dusting spray, with no reported sequelae). The patient had self-described exposure to asbestos, without medical treatment. No history of surgical procedures or blood transfusions was elicited.

Allergies: No drug allergies or reactions were recorded.

Medications: One Centrum multivitamin daily; acetaminophen p.r.n. for occasional headache.

Family History: The patient's father had hypertension, coronary artery disease, and a history of myocardial infarction. His mother was alive and in good health. His grandmother died from a brain tumor of unknown type. His paternal grandfather and maternal uncle also had coronary artery disease. One sister and two brothers were in good health. The patient had two adult children in good health. There was no family history of Alzheimer's disease or other dementing illnesses, psychiatric problems, or stroke.

Social History: The patient quit drinking a few months prior to presentation, without apparent improvement in any of his symptoms. He previously had consumed two drinks of rum a day for many years. There was no history of tobacco use or IV drug abuse. He had completed high school and one year of college. He worked on a farm when he was a teenager. He had previously worked as an accountant, and his most recent work was a job installing telephones. There is no known exposure to tuberculosis. The patient had vacationed extensively in Latin America, particularly in Mexico, but did not report any history of infections acquired during his travels. He was a frequent outdoorsman, who enjoyed elk hunting and eating wild game. There was no history of tick infestation, contact with sick animals, or animal bites. The family has a dog and a cat, apparently healthy, with no exotic pets.

Review of Systems: The patient experienced a 60 pound weight loss over the past several months, but he and his wife attributed this to voluntary dieting with the aid of a Metabolife dietary supplement program. His wife, on the same regimen, had experienced only mild weight loss. There were no reported sleep disturbances, fevers, nausea, vomiting, change in bowel or bladder habits, headache, weakness, sensory loss or other neurological complaints. No diarrhea, skin rashes, pulmonary or cardiac symptoms were reported.

Physical Exam

General: Pleasant and cooperative, middle-aged gentleman appearing his stated age, well nourished and in no acute distress.

Vital Signs: Temperature: 97.0 F, pulse 84/min, respiratory rate 14/min, blood pressure 116/82 mmHg.

HEENT: Normocephalic, without evidence of trauma. Sclerae and conjunctivae clear. Nasopharynx and oropharynx clear. Mucous membranes moist.

Neck: Supple, no lymphadenopathy, no jugular venous distension, no bruits.

Chest: Clear to auscultation.

Cardiovascular: Regular rate and rhythm, normal S1 and S2, no S3, no murmurs.

Abdomen: Soft, nontender, nondistended; no organomegaly; normal rectal exam with stool guaiac negative.

Extremities: No clubbing, cyanosis or edema.

Skin: No rashes; scattered acne on the upper back of longstanding duration; no other lesions.

Neurological Examination

Mental Status: 27/30 (-3 for errors in spelling "world" backwards). Mild but consistent slowing was observed on responses to questions.

Speech: Fluent with normal repetition and comprehension. Normal labial, lingual and guttural articulation.

Cranial Nerves: I. Not tested. II-XII grossly intact, with pupils equally round and reactive to light and accommodation, no visual field deficits, visual acuity was 20/20 bilaterally with reading glasses, extraocular movements were intact throughout without nystagmus. There was no limitation of vertical gaze movements. Sensation was intact throughout the three divisions of the trigeminal nerve, corneal reflex, hearing, gag were intact bilaterally. Intact sternocleidomastoid and trapezius strength. Tongue was midline without atrophy or fibrillations.

Motor: Strength 5/5 in all major muscle groups, with no atrophy or fasiculations noted. Normal tone, no cogwheeling. No abnormal or involuntary movements noted during a detailed interview.

Reflexes: 2+, without clonus or spread. No Hoffman, Babinski, snout, or glabellar responses. There was no accentuated jaw jerk.

Sensation: Intact to all modalities throughout. Romberg negative.

Cerebellar: Intact finger to nose, heel to shin and rapid alternating movements.

Gait: Normal tandem walking, heel and toe walking.

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