History and Physical — Patient 68

History

Present Illness: The patient is a 46-year-old Hispanic female with non-insulin-dependent diabetes mellitus, who was in her usual state of health until two days prior to admission. At that time, she developed generalized fatigue. One day prior to admission, she complained of right leg pain, subjective fever, and a generalized dull headache. Her family reported that she had decreased strength and sensation in her legs. Her husband noted increased fluid intake and urination during the night prior to presentation; he also reported episodes of "talking but not making sense." On the morning of presentation, the patient developed persistent nausea, with several episodes of vomiting of non-bloody, non-bilious material. She presented to the emergency room at the Ben Taub General Hospital with generalized weakness and decreased communication. Based on initial clinical assessment and laboratory screens suggesting diabetic ketoacidosis, admission orders were written for further evaluation and treatment. Intravenous infusions of insulin and fluids were started. Lorazepam, 2 mg, was administered for agitation, with improvement in the patient's mental status.

While the patient was waiting for a bed assignment, she developed weakness in the right leg. Her mental status abruptly deteriorated a few minutes later. Her speech became incoherent, and she pulled out her intravenous fluid catheter. The admitting physician noted the appearance of anisocoria and left-sided weakness that were not present on the patient's arrival to the emergency room. Within ten minutes, she became more alert, following commands. A few minutes later, she abruptly stopped following commands, demonstrating episodic right gaze preference and diminished voluntary movements of the left side. Consultation with the Neurology Service was requested, on an emergency basis.

Past Medical History: The patient had a lengthy history of non-insulin dependent diabetes mellitus, preceded by gestational diabetes about 15 years earlier. One year prior to this presentation, she had an episode of severe hyperglycemia (without ketoacidosis) requiring hospital admission. She has documented diabetic retinopathy. Within the past two years, she has had several skin infections along her waistline, requiring physician consultation.

Past Surgical History: Caesarian section 15 years ago.

Allergies: No known drug allergies.

Medications: Glyburide-metformin tablets, and multivitamins.

Social History: The patient is married and living with her husband. She has three daughters and two sons; one of her sons is currently living with her and her husband. She has no history of tobacco or drug use, and she drinks alcoholic beverages only occasionally.

Family History: There is no history of coronary artery disease, diabetes or stroke in the family. The patient had no contacts with sick persons immediately prior to her presentation.

Review of Systems: Obstetric history: She is G5, P5. The patient and her family were unable to provide additional detailed information.

Physical Exam

General: An agitated, middle-aged female mumbling incoherently as the examiner approached.

Vital Signs: Blood pressure in the supine position ranged between 112/69 and 152/91 mmHg, increasing during periods of agitation. Pulse ranged between 120 and 146/min. Temperature was approximately 97 F on repeated assessments. Respirations were 18 to 24/min, and deep.

HEENT: Normocephalic, no evidence of trauma. Anicteric sclerae; conjunctivae pink. Tympanic membranes clear and intact bilaterally. No nasal drainage noted. The oropharynx showed no erythema or exudates.

Neck: Supple with full range of motion; no masses or bruits noted.

Chest: Lungs clear to auscultation bilaterally.

Cardiovascular: Tachycardic with regular rhythm, normal S1 and S2 heart sounds. No murmurs, rubs or gallops were heard.

Abdomen: Soft, non-tender; no hepatosplenomegaly. Bowel sounds present throughout. A 2-3 cm irregular scar along the waistline was present, consistent with the history of prior cutaneous infection.

Extremities: No cyanosis, clubbing or edema. No rashes or other skin markings were noted.

Neurological Examination

Mental Status: At her best level of function, the patient was oriented to person and place. During the examination, her speech varied from fluent and appropriate to completely incoherent. She complained of headache. She was able to follow simple commands intermittently.

Cranial Nerves: The right pupil was 3 mm and unreactive to light; left pupil was 2 mm and sluggishly reactive to light. The patient demonstrated a right gaze preference. Initially, an oculocephalic maneuver did not cause eyes to cross midline. Later in the exam, a full range of motion of eye movements was obtained voluntarily. The patient had a left lower facial droop. Her tongue deviated to the left.

Motor: On initial assessment, the patient was able to move all extremities equally against gravity. However, she was unable to move the left side against gravity later in the examination.

Reflexes: Deep tendon reflexes were present in all limbs. Babinski responses were present to plantar stimulation bilaterally.

Tone: Increased in the lower extremities, right greater than left. Tone in the upper extremities is normal.

Sensation: The patient withdrew to painful stimuli applied to all four extremities, but withdrawal was less brisk on the left side.

Coordination: No gross abnormalities of coordination were noted with observation of spontaneous movements.

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