History and Physical — Patient 74

History

Chief Complaint: Dizziness

Present Illness: The patient is a 35 year old African-American man, in his usual state of good health until five months prior to admission. At that time, he developed a pruritic rash on his trunk that spread centripetally to involve his entire body. He received no treatment for the rash, and it had risen to no more than the level of an annoyance.

Over the past two and a half months, the patient began to lose weight, and reports that he lost 70 pounds. The patient denies abdominal pain, nausea, and vomiting during most of this time. He states that he simply had a loss of appetite.

Over the two weeks preceding admission, the patient developed nausea and vomiting, associated with unsteady gait. In addition, he noted slurring of his speech. He denies any focal weakness or sensory deficits, and states that his current difficulties came on subacutely and were not maximal at onset, but have gradually worsened with time.

Past Medical History: Minor ear infections as a child. Occasional bouts of shingles in a trigeminal distribution throughout his life. No surgeries.

Allergies: "Topical Iodine".

Medications: None.

Social History: No tobacco. Drinks approximately one alcoholic beverage a day. No illicit drug use. Recently divorced heterosexual, with only one sexual partner in the past two years (his ex-wife). The patient was in the Navy, during which time he traveled to Brazil, St. Thomas, Chile, and Acapulco. He has not traveled outside the United States in the past six years, however. The patient has two dogs, no cats, and no birds.

Family History: His father died at age 64 due to complications of cancer (melanoma). His mother died at age 68 due to myocardial infarction. Two brothers and two sisters are alive and well.

Review of Systems: Except as outlined above, a review of systems was unremarkable.

Physical Exam

General: Sleepy African-American man lying on a stretcher in the emergency room, looking uncomfortable.

Vital Signs: Temperature 103.2 F; Pulse 123/min.; Blood Pressure 148/92 mmHg; Respirations 20/min.

HEENT: Anicteric sclerae. Oropharynx with red tongue and no thrush, no petechiae noted on buccal mucosa or conjunctivae. Cerumen present in both ears, but tympanic membranes with good light reflex, no erythema.

Neck: No nuchal rigidity, no carotid bruits appreciated, and no cervical lymphadenopathy.

Chest: Clear to auscultation in all fields.

Cardiovascular: Tachycardic with a 2/6 systolic murmur heard at the apex, without radiation.

Abdomen: Soft, non-distended and non-tender, with bowel sounds present.

Extremities: No clubbing, cyanosis, or edema. No Osler's nodes or Janeway lesions. No splinter hemorrhages seen. Full range of motion in joints.

Neurological Examination

Mental Status: The patient is sleepy but easily arousable and able to maintain a conversation. He is oriented to person and time; not oriented to place.

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

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils equal, round, reactive to light. Visual fields full to confrontation. Fundoscopic exam normal.
III / IV / VIExtraocular movements intact without nystagmus.
VSensation intact on both sides of the face.
VIILeft lower facial droop present.
VIIIHearing intact to finger rub bilaterally.
XPalate elevates in the midline without uvular deviation.
XISternocleidomastoid strength 5/5 bilaterally.
XIITongue protrudes in the midline (though initially the appearance of deviation is given by the facial droop).

 

Motor:

Strength

Right

Left

Upper Extremities

  
Deltoid54+
Biceps54+
Triceps55-
Wrist Extensors54
Wrist Flexors54+
Finger Extensors54
Finger Flexors54+

Lower Extremities

  
Iliopsoas55
Knee Extensors55
Knee Flexors55
Ankle Dorsiflexors55
Ankle Plantarflexors55

 

Reflexes:

Reflexes

Right

Left

Biceps2+2+
Triceps2+2+
Brachioradialis2+2+
Patellar2+3+
Ankle2+4+ (8 beats of clonus)

 

Sensation: No deficits to light touch, pinprick, proprioception, temperature, or vibration in any extremity. No extinction to double simultaneous stimulation.

Coordination: The patient performs finger to nose testing normally on the right, demonstrates marked dysmetria on the left. He performs heel to shin testing normally on the right, demonstrates marked incoordination on the left. Rapid alternating movements are slow and inaccurate on the left as compared to the right.

Gait: Grossly unsteady.

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