History and Physical — Patient 65

History

Chief Complaint: Right arm weakness.

Present Illness: A 50 year-old, right-handed Caucasian male with recent onset fever and neck stiffness was transferred from another hospital to the Houston Veterans Administration Medical Center. The patient had been in his usual state of health until one week prior to admission when he developed fever, chills, headache, reduced appetite, a "sore neck", mild right upper extremity weakness, bilateral arm muscle "twitches", and diplopia. After one week of increasing symptoms (mid-July, 2002), he went to the admitting hospital, where a lumbar puncture was performed. Based on the results of CSF studies, the patient was treated with 2 grams of ceftriaxone for a presumed bacterial meningitis, and then transferred to the Medical Service at the Houston V.A. Medical Center for continued treatment.

On the day of transfer, physical examination documented a temperature of 102.4 degrees F, with "sluggish pupils", otherwise intact cranial nerve functions, 4/5 right arm muscle strength, and 2+ reflexes throughout. To his initial regimen of ceftriaxone, vancomycin and acyclovir were empirically added. Acetaminophen tablets were given as needed for fever or pain.

On the second hospital day, the Neurology Service was consulted to evaluate a marked worsening of the patient's right upper extremity weakness, with strength rated at 3/5 in most major muscle groups of the right arm. At this time, he was unable to open a wrapped package of silverware or to feed himself due to weakness. He had never experienced weakness in his arm previously. He denied burning, numbness, tingling, arm pain or other sensory abnormalities. He denied any bladder or bowel incontinence. The patient also complained of double vision, describing it as similar to the double vision that he had transiently experienced following head trauma in 1974.

On the fifth hospital day, his condition deteriorated again, with the development of lethargy, mild dysarthria, and further worsening of his right upper extremity weakness (2/5 proximately, 3-/5 distally). By this time, tendon reflexes in the right arm had become unobtainable. A CT scan of the head showed no acute changes.

Past Medical History:

  • The patient had head trauma in 1974 after falling 30 feet from a tower onto concrete. At that time, blood had exuded from his left ear, and he was hospitalized for one month. He denied any surgery related to this trauma. He had diplopia following the accident, but it resolved shortly thereafter. He also developed a left upper quadrantanopia in association with the accident, which has remained unchanged since then.
  • A history of polysubstance abuse including cocaine, IV drugs, and cannabis. The patient denies recent use of illicit substances.
  • Alcohol: 5-6 beers per day.
  • Tobacco: 1 pack of cigarettes per day for 15 years.
  • Multiple remote fractures associated with falls.

Allergies: No known drug allergies.

Medications: There were none taken at home, prior to hospitalization. Medications given at transfer were as above. Medications at the time of consultation included acyclovir, thiamine, folate, and multivitamins.

Social History: The patient lives with his wife near the Texas-Louisiana border, and works on air conditioners as a repairman. He has had no problem lifting air conditioners until the onset of his present illness.

Family History: The patient's father had a myocardial infarction. His mother had hypertension and an aneurysm (not otherwise specified). There were no neurological diseases reported in the patient's family.

Physical Exam

General: The patient was drowsy, and at times anxious during the examination.

Vital Signs: Temperature 100.5 degrees F, Pulse 64/min., Respirations 20/min., Blood Pressure 119/69 mmHg.

HEENT: Normocephalic, and the oropharynx was clear. Hyposphagma of the left eye was evident.

Neck: There was nuchal rigidity present. No thyromegaly or carotid bruits were appreciated.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops heard.

Abdomen: Mildly distended, non-tender, bowel sounds present, no hepatosplenomegaly palpated.

Extremities: No edema, clubbing or cyanosis. No skin rashes or lesions evident.

Neurological Examination

Mental Status: The patient was initially alert and oriented to time, place, person and situation. On the fifth hospital day, he was disoriented. He was somewhat drowsy and at times was agitated and had difficulty cooperating with the examination. When attention was directed to the task, his speech was fluent, without labial, lingual or guttural dysarthria.

Cranial Nerves:

Cranial Nerves

Findings

INot assessed.
IIAn afferent pupillary defect was present on the left. The right pupil was 3 mm, reactive to 2 mm. The funduscopic exam revealed left optic disc atrophy, without any papilledema. A left upper quadrantanopia is apparently unchanged since the head trauma in 1974. Uncorrected vision was 20/200 in the left eye and 20/40 in the right eye.
III / IV / VIThe patient sat with his head tilted to the left and complained of diplopia when looking downwards and close to his nose. There was horizontal nystagmus involving the left eye.
VIntact facial sensation, and intact strength of masseters and temporalis bilaterally. Normal corneal responses bilaterally.
VIIFacial musculature had normal strength, with symmetric expression.
VIIIHearing was intact to finger rubs bilaterally.
IX / XThe palate was midline and raised symmetrically. The gag reflex was present.
XISternocleidomastoids and the trapezii had normal strength bilaterally.
XIIThe tongue protruded in the midline with no atrophy or fibrillations.

 

Motor: Strength was initially 3/5 for the right deltoid, biceps, brachioradialis, wrist extensors, wrist flexors, finger extensors, and finger flexors. On the fifth hospital day, the strength in major muscles of the right arm was 2-/5 proximally, and 3-/5 distally. Otherwise the patient's strength was 5/5 throughout. There was no atrophy, fasciculations, or change in tone.

Reflexes: 3+ in the left upper extremity. Symmetric and 3+ at the knees with distal spread and crossed adduction. 3+ ankles bilaterally. The right upper extremity reflexes (brachioradialis, biceps and triceps) were initially decreased in comparison to the other extremities. By the fifth hospital day, reflexes in the right arm were absent. The jaw jerk was normal. Glabellar tap and palmomental responses were absent.

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

Coordination: Heel-to-shin maneuvers were normal bilaterally. Finger-to-nose maneuvers were normal on the left, but untestable on the right because of weakness. Rapid alternating movements were normal on the left. There was no loss of check of flexion movements, and no titubation.

Gait: The gait was unsteady and wide-based. He had difficulty with tandem gait. Gait on his heels and on his toes showed no disproportionate difficulty.

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