History and Physical — Patient 73


Present Illness: A 57 year old man presented to the Neurology Clinic at the Houston Veterans Administration Medical Center, complaining of worsening memory and difficulty with naming relatives and celebrities. He was a foreign currency trader employed by a local company. He noted little difficulty performing at work and usually worked a 10 hour day. He described his job as a high-pressure, high-demand profession requiring constant vigilance and high-speed decision making. At the time of presentation, he had noted difficulties with memory and name recall for about six months. He described problems during social events as he could not recall names of relatives and acquaintances. Recall for proper names and entities was disproportionately affected compared to other words. To illustrate this, he stated he could not name nearly as many film stars as he was able to do in the past. Also, he was experiencing episodes during which he could not speak and "blanked out" with some confusion afterwards. These episodes occurred about twice a month. He had not noted difficulties with any other cognitive abilities, and no motor or sensory symptoms had occurred.

Past Medical History: Three years prior to the current illness, he received a diagnosis of a T4N1M0 squamous cell carcinoma of the left tonsil, with extension into the nasopharynx and to the middle ear via the eustachian tube. Intensive radiation therapy with the "Peacock" protocol was administered, and the patient has been in remission since then, with frequent surveillance by the otolaryngology service. His last head CT was performed two months before he presented for neurologic evaluation. Severe motor vehicle accident in the 1970's, with multiple facial fractures, ankle fracture and prolonged hospitalization. Crohn's disease, s/p multiple abdominal surgeries, currently in remission.

Medications: Aspirin, on occasion.

Social History: Foreign currency broker, and insurance broker. Long term monogamous relationship. Never smoked. Occasional social alcohol intake. No drugs.

Family History: The patient's father died of lung cancer in his 60's. His mother died of renal failure, also had congestive heart failure, diabetes and emphysema.

Review of Systems: Denies weight loss, fevers, sweats, or other constitutional symptoms. Denies headache, diplopia, visual blurring. Stable hearing loss in left ear attributed to chronic middle ear effusion - myringotomy previously attemped with no fluid seen. No bleeding, dark stools, or abdominal cramping. No symptoms referable to other organ systems.

Physical Exam

General: Very pleasant and cooperative gentleman in business attire. All vital signs are normal.

HEENT: Post-radiation skin changes over the left side of the head and neck. Sclerae anicteric. Nose and nasopharynx clear. Oropharynx clear with healthy mucosa. Right tympanic membrane clear. Left ear moist, no purulence, eardrum opacified. Mobile larynx, no lesions.

Neck: Supple. No palpable lymphadenopathy. No bruits heard.

Chest: Clear to auscultation. Normal cardiac rate, rhythm, normal heart sounds.

Abdomen: No organomegaly. Soft, nontender, nondistended.

Musculoskeletal: Full range of joint motion, without pain.

Extremities: No cyanosis, edema or skin lesions.

Neurological Examination

Mental Status: Very alert, fully oriented. Occasional word finding difficulties for infrequently encountered items were observed during the interview. Folstein Mini-Mental Status Exam (MMSE) score 27/30 (-3 for recall).

Speech: Fluent with mild dysarthria. No errors in comprehension or repetition.

Cranial Nerves: Pupils 6mm on the right, 5 mm on the left; both reactive to light. Extraocular movements intact. Normal facial sensation. Diminished nasolabial fold on the left side, a residual deficit from facial injuries during previous accident (present on old driver's license). Hearing decreased on the left side. Normal palatal elevation and phonation. Sternocleidomastoid and trapezius strength intact. Normal tongue strength, without atrophy or fibrillations.

Motor: Normal tone, athletic build. No pronator drift. Strength 5/5 throughout.

Reflexes: Deep tendon reflexes 2+ throughout, with mild asymmetry in upper extremities (right greater than left). Bilateral Hoffman's signs are present, right more pronounced than left. Plantar responses are flexor. Negative glabellar, snout, palmomental responses.

Sensation: Intact to all modalities.

Coordination: Coordination and fine motor abilities normal.

Gait: Unremarkable with normal stance and stride length; good tandem gait, normal heel and toe walking. The patient can balance on one leg without difficulty, hop on either leg equally well. Romberg negative.

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