History and Physical — Patient 61

History

Present Illness: The patient is a 60 year old, black male with history of a stroke two years ago, who presents to the Houston Veterans Administration Medical Center with left arm and leg weakness for the past two days. He also complains of liquids drooling from the left corner of his mouth over the same time period. He denies a sudden onset to his symptoms, headache, or change in level of alertness. On the morning he came to the Emergency Department, he had attempted to get out of the bed, but had fallen because his left leg was weak. His speech had been slurred in the morning, but the patient believes this has now resolved.

He reports that he had a stroke two years ago which resulted in left arm and leg weakness. These deficits improved substantially with rehabilitation, such that his baseline status prior to two days ago was good ambulation with a cane, and slight dragging of his left foot. He denies any oral incontinence at his baseline prior to two days ago. On further questioning, the present illness appears to reproduce his symptoms from his stroke two years ago. He has had no other episodes of weakness, numbness, speech or swallowing change, or visual change.

Past Medical History: (1) Non-insulin dependent diabetes mellitus; (2) Essential hypertension; (3) Obesity; (4) Sleep apnea; (5) Stroke two years ago; (6) Stasis dermatitis.

Past Surgical History: (1) Cholecystectomy; (2) Appendectomy.

Allergies: Penicillin causes altered mental status, by the patient's description.

Medications: Enteric-coated aspirin 325 mg qd; clonidine 0.1 mg tid; furosemide 80 mg qd; glyburide 10 mg bid with meals; lisinopril 40 mg bid; metformin 850 mg every 8 hours with food; methocarbamol 750 mg every 8 hours/as needed for muscle spasm; multivitamin daily; orlistat 120 mg tid with meals; simvastatin 40 mg qd; verapamil SA 240 mg every 12 hours; elastic bandages, bacitracin, becaplermin topical gel, 0.1% triamcinolone acetonide ointment for stasis ulcer.

Social History: He stopped smoking 13 years ago. He denies drinking alcohol or using illicit drugs. He lives alone.

Review of Systems: He denies dysphagia, fever, chills, diarrhea, melena, hematochezia, chest pain or shortness of breath. He has not lost weight recently, but has felt fatigued. He was taking an antibiotic until one week ago for a venous stasis ulcer in the left lower extremity. He receives dressing changes for the ulcer and states that his dermatologist has told him the ulcer is healing as would be expected.

Physical Exam

General: Morbidly obese black male in no acute distress. He is pleasant and cooperative during the examination.

Vital Signs: Temperature 97.4 F; blood pressure 138/75 mm Hg; pulse 78/min; respirations 18/min.

HEENT: No cranial abnormalities. Oral cavity without lesions and with moist mucus membranes. Conjunctival pallor is present. Neck supple without lymphadenopathy.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Regular rate and rhythm with distant heart sounds; no murmurs heard; no jugular venous distention.

Abdomen: Obese, nontender, normoactive bowel sounds throughout. Right inguinal hernia present. Healed surgical scars present.

Extremities: 1+ pitting edema in ankles bilaterally. Healing stasis ulcer on left leg. Symmetric leg girth.

Neurological Examination

Mental Status: Alert and oriented; intact verbal fluency, repetition, and comprehension. No neglect evident.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils equally round and reactive to light. Inconsistent left hemianopsia on direct confrontation testing. Fundoscopic examination normal.
III / IV / VIExtraocular movements intact without nystagmus.
VNormal sensation in V1-V3 distributions.
VIILeft sided facial droop with sparing of forehead.
VIIIHearing intact.
IX / XPalate symmetrically elevates.
XISternocleidomastoid with full strength bilaterally.
XIITongue with normal bulk; protrudes midline.

 

Motor: Neck flexors and extensors 5/5 strength. Strength in right upper extremity: 5/5 throughout. Strength in left upper extremity: deltoid 4/5; triceps 4/5; biceps 3/5; wrist extensors and flexors 3/5; finger extensors and flexors 2/5. Strength in right lower extremity: 5/5 throughout; Strength in left lower extremity: iliopsoas 4/5; quadriceps 5-/5; knee flexors 4/5; ankle dorsiflexion and plantar flexion 1/5.

Reflexes: Biceps and brachioradialis 3/4 on the left with spread; 2/4 on the right; Triceps 2/4 on the left; 1/4 on the right; patellars 3/4 on the left; 2/4 on the right; Achilles tendon 2/4 on the left; 1/4 on the right.

Coordination: Intact finger-nose and heel-shin motions. Rapid alternating movements intact on the right, but could not test on the left secondary to weakness.

Gait: Circumduction gait with decreased weight-bearing on the left. No antalgic component evident.

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