History and Physical — Patient 62


Present Illness: This is a 51 year old Asian female presenting to the Neurology Clinic of the Ben Taub General Hospital with complaints of double vision, difficulty swallowing, and altered sensation on the left side of the face. These problems have been progressive over the last several months, and are accompanied by a dull, left-sided headache. More recently, the patient has developed hoarseness, together with some difficulty swallowing solid foods. She denies fever, chills, neck stiffness, nausea or vomiting.

Past Medical History: No other acute or chronic medical problems noted.

Past Surgical History: She underwent left parotidectomy in six years ago for unknown reasons. She has also had a cholecystectomy and a bilateral tubal ligation, remote to the present illness.

Allergies: No known drug allergies.

Medications: None.

Social History: No history of alcohol, tobacco, or illicit drug use.

Family History: No history of neurologic disease in the family.

Review of Systems: There has been no recent weight gain or loss, and the patient has not noted any rashes or other skin lesions. She denies xerostomia or xerophthalmia, recent upper respiratory illness or sinusitis, or dyspnea.

Physical Exam

General: Middle-aged Asian female in no apparent distress.

Vital Signs: Blood pressure 134/79 mm Hg; pulse 92/min, regular; respirations 14/min, temperature 98.4 F.

HEENT: Normocephalic; no evidence of trauma; conjunctivae are clear; oropharynx is clear; neck is supple without meningismus or lymphadenopathy.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Regular heart rate and rhythm with no murmurs, rubs, or gallops. Normal peripheral pulses.

Abdomen: Soft, nontender, nondistended, with (+) bowel sounds. No organomegaly.

Extremities: No cyanosis, clubbing, or edema. No rashes noted.

Neurological Examination

Mental Status: Awake, alert and fully oriented.

Speech: Fluent with intact repetition and comprehension. No dysarthria noted.

Cranial Nerves: Pupils are equal, round and reactive to light and accommodation. Visual acuity intact; funduscopic examination shows no papilledema or retinal lesions. No ptosis is evident. There is decreased abduction in the left eye; otherwise extraocular movements are intact. Sensation on the left side of the face is decreased to light touch and pinprick in all distributions of the trigeminal nerve. Strength and bulk of the masseter and temporalis are symmetrical. The corneal reflex is intact bilaterally. Facial expression is symmetric with no clear weakness of the orbicularis oculi or orbicularis oris. Hearing is decreased in the left ear compared to the right, with lateralization on a Weber test to the right ear, and a Rinne test showing no enhancement of bone conduction over air conduction in either ear. There is no nystagmus. The uvula deviates to the right. Sternocleidomastoid strength is 4/5 on the left and 5/5 on the right. The tongue protrudes in the midline. Fibrillations are noted on the left side of the tongue, but there is no marked tongue atrophy.

Motor: Strength in the left arm is 3/5 at the deltoid, 4/5 in the biceps and triceps, but is otherwise 5/5. Strength is 5/5 in all other muscle groups.

Reflexes: Tendon reflexes are 2+ and symmetric throughout.

Sensation: Intact to light touch, pinprick, proprioception, and temperature throughout.

Coordination: There is no tremor, dysmetria, or loss of check of flexion movements out of proportion to strength. Rapid alternating movements are intact bilaterally.

Gait: Able to heel walk, toe walk, and tandem walk normally, accounting for a slight asymmetry in left arm swing.

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