History and Physical — Patient 60
Chief Complaint: "I cannot move my left side."
Present Illness: The patient is a 47 year old right-handed female diagnosed with right otitis media in early October, 2001. Despite treatment with multiple oral antibiotics over three months, she complained of persistent right jaw and ear pain as well as decreased hearing in her right ear. Near the end of the year, she developed acute shortness of breath while shopping and presented to an outside emergency room, where she was diagnosed with recurrent otitis and bronchitis. She was discharged home with a 10 day course of oral levofloxacin. The following morning, however, she awakened with right face and left arm and leg weakness, and returned to the emergency room. Laboratory studies were remarkable for markedly elevated serum glucose, an increased anion gap and ketones in the serum and urine. Insulin and intravenous fluids were administered, and the patient was transferred to the Methodist Hospital for evaluation and management of a suspected stroke in evolution, superimposed upon diabetic ketoacidosis.
After arrival at the Methodist Hospital, the patient continued to complain of persistent right jaw and ear pain. She also complained of left sided weakness, a droopy right eyelid, diminished vision, and inability to look at objects on her left unless she turned her head. She could not describe the exact progression of her symptoms, but felt that her condition had not worsened during transfer to the Medical Intensive Care Unit. Neurologic consultation was urgently obtained.
Past Medical History: Remote cesarean section, without complication. No known history of diabetes mellitus.
Allergies: No known drug allergies.
Medications: Levofloxacin 500 mg po q.d.
Family History: The patient's mother and father have been diagnosed with coronary artery disease, hypertension and diabetes mellitus. There is no family history of stroke.
Social History: The patient denies any history of alcohol, tobacco or illicit drug use. She currently lives with her husband and works as a florist. She has two adult children.
Review of Systems: The patient reports some clear nasal discharge prior to her admission to the hospital, which she had believed was due to exposure to Christmas greenery at the florist's shop. She denies any fever or chills, weight loss or weight gain, excessive urination, nocturia, swallowing or speech problems, chest pain, heart palpitations, change in bowel movements, history of endocrine or hematological problems, headache or difficulties with numbness or weakness prior to her current complaints.
General: Well-developed, well-nourished female, lying in bed with her eyes closed, in no apparent distress.
Vital Signs: Blood pressure, 161/87 mmHg; Temperature, 97.5 F; Heart rate, 133/min, regular; Respirations: 24/min.
HEENT: Minimal edema of the right periorbital area is noted. Mucus membranes moist, sclera anicteric, oropharynx clear. A small amount of bloody discharge is evident in the right nares.
Neck: Supple without lymphadenopathy or jugular venous distention. No bruits heard.
Chest: Clear to auscultation bilaterally.
Cardiovascular: Tachycardic with regular rhythm. No murmurs, gallops or rubs were heard.
Abdomen: Non-tender without any rebound or guarding. Bowel sounds present. No organomegaly noted.
Extremities: No clubbing, cyanosis or edema. No rashes or other lesions noted.
Mental Status: The patient was lethargic, but easily arousable. Folstein Mini-Mental Status Examination: 27/27 (tasks involving reading and writing were not completed due to markedly decreased visual acuity). Speech was fluent with good repetition and comprehension. The patient was aware of her deficits. She exhibited no obvious neglect.
|II||Right pupil 5 mm, non-reactive to direct light stimulation. Left pupil 4 mm, reactive to direct light stimulation. An afferent pupillary defect is present on the right. Visual acuity: Able to count fingers on the right; 20/200 on the left.|
|III / IV / VI||Complete ophthalmoparesis on the right. Intact adduction on the left, with some limitation of abduction, upgaze and downgaze. Complete ptosis of the right eyelid is present.|
|V||Intact sensation to light touch and pinprick in all three divisions of the trigeminal nerve bilaterally.|
|VII||Decreased movement of the frontalis and orbicularis oris on the right, with obvious facial asymmetry. Absent response on the right to corneal stimulation on either side.|
|VIII||Hearing decreased to finger rub on the right. Weber's test lateralized to the right.|
|IX / X||Intact gag response and palatal elevation.|
|XI||Mildly reduced (4/5) strength in both sternocleidomastoids.|
|XII||Tongue protrudes in the midline without fibrillations or atrophy.|
Motor: Normal (5/5) strength of right deltoid, biceps, triceps, brachioradialis, wrist extensors, wrist flexors, finger extensors and flexors, iliopsoas, knee extensors and flexors, ankle dorsiflexion and plantar flexion.
Strength is 0/5 in the left deltoid, biceps, triceps, brachioradialis, wrist extensors, wrist flexors, finger extensors and flexors, iliopsoas, knee extensors and knee flexors. Strength is 1/5 for left ankle dorsiflexion and plantar flexion. No atrophy or increase in tone noted.
Reflexes: Trace tendon reflexes in both biceps, brachioradialis, triceps, patellar, and Achilles. An upgoing toe is noted with plantar stimulation on the left, and a downgoing response on the right. Glabellar and snout responses are absent, and the jaw jerk is not enhanced. Hoffman responses are absent bilaterally.
Sensation: Decreased to pinprick, light touch, vibration and proprioception in the left upper and lower extremities.
Coordination: The patient was able to perform finger to nose (if the examiner's finger was placed centrally or to the patient's left), rapid alternating movements and heel to shin maneuvers using her right arm and leg. These tests could not be tested on the left due to left-sided weakness.
Gait: Not tested.