History and Physical — Patient 76

History

Chief Complaint: Leg weakness

Present Illness: The patient is a 43 year old right-handed female with a history of polysubstance abuse, borderline personality disorder, and previous suicide attempts. She presented to the Ben Taub General Hospital after an overdose of paroxetine (Paxil), zolpidem (Ambien), crack cocaine and cannabis. Upon her presentation to the emergency room, she stated, "Today is the anniversary of my daughter's death and I took a bunch of pills because I wanted to die." Throughout her initial emergency evaluation, she was normotensive. She was given intravenous fluids as well as activated charcoal, and a gastric lavage was performed. After being deemed medically stable, she was admitted to the Psychiatry Service for further management.

While being evaluated by the Psychiatry Service, the patient was uncooperative with interviews. She responded to questions with only one word answers or short phrases and often seemed to feign sleeping in order to avoid conversation. She did not offer either complaints or conversation spontaneously. Her mother reported a history of multiple suicide attempts by ingestion of a plethora of different pills and illicit drugs, as well as chronic polysubstance abuse since age 18. Her mother also reported that the patient would feign sleep when she did not wish to interact with those around her.

During the patient's admission, she remained in bed and was uncooperative with other patients, and even more so with medical staff. She maintained appropriate levels of alertness during the day and intermittently would make one- to two-word requests for television, food, cigarettes and crack cocaine. She denied hallucinations, suicidal ideation, or symptoms of depression. The psychiatry team did not at any time find her to be psychotic.

On day 3 of her hospital admission, the patient's temperature rose to 102.7 F, with cough productive of yellow sputum. She was repeatedly found with urine-soaked bedclothes. In addition, no spontaneous movements of her legs were noted even in response to noxious stimuli. The Medicine Service was consulted to evaluate the patient's fever and cough. The Neurology Service was consulted to evaluate the patient's immobility.

Past Medical History: Remarkable for hypertension, major depression, and obesity. There is no known diabetes, cancer, cardiac disease or hypercholesterolemia. The patient has had no surgical procedures.

Allergies: No known drug allergies.

Medications: Preadmission — Paroxetine (Paxil), dosage unknown; zolpidem (Ambien), dosage unknown. At time of Neurology evaluation — Lorazepam (Ativan) 2 mg i.m. q 4 hr.; haloperidol (Haldol) 5 mg i.m. q 4 hr.; benztropine (Cogentin) 1 mg i.m. q 4 hr.; acetaminophen (Tylenol) 650 mg as needed; diphenhydramine (Benadryl) 50 mg at bedtime.

Social History: Significant for alcohol, cannabis, cocaine and tobacco use. The patient currently lives alone. She has two living adult children with whom she does not have contact.

Family History: No known cancer, diabetes, or heart disease. The patient's daughter had died years before, from a motor vehicle accident.

Review of Systems: No overt chest pain, shortness of breath, headache, vision changes, weight loss, back pain, nausea, vomiting, or chills.

Physical Exam

General: Overweight female, not interacting with the examiner.

Vital Signs: Blood pressure: 188/86 mmHg; temperature: 102.7 F; pulse rate: 74 per min; respiratory rate: 18 per min; pulse oximetry: 96% saturation on room air.

HEENT: Normocephalic, without evidence of trauma. Oropharynx was clear. Mucous membranes were moist.

Neck: Supple with no carotid bruits, jugular venous distention or thyromegaly.

Chest: Coarse breath sounds bilaterally with good air movement throughout.

Cardiovascular: Regular rate and rhythm without murmurs, rubs, or gallops.

Abdomen: Soft, nontender and nondistended with normally active bowel sounds.

Skin: No rashes noted.

Extremities: No clubbing, cyanosis, or edema. Distal pulses were palpable in all 4 extremities.

Neurological Examination

Mental Status: The patient appeared somnolent, but aroused fully to voice. She refused to sit up or to get out of bed. She displayed marked psychomotor retardation. There was poverty of speech and marked apathy. Her affect was constricted, and thought process and content were difficult to assess. The patient did not answer most questions, but in one instance did respond correctly as to her location.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils equal, round and reactive to light.
III / IV / VINo voluntary movements to follow the examiner?s finger. Oculocephalic maneuvers demonstrated adequate movement of the eyes across midline in horizontal and vertical directions.
V / VIIShe displayed symmetric facial grimace and forced eye closure during supraorbital stimulation.
VIIIUnable to evaluate fully due to lack of cooperation.
IX / XA gag reflex was present bilaterally.
XIIUnable to assess tongue strength. There was neither atrophy nor fibrillation of the tongue.

 

Motor: Intermittent, spontaneous, antigravity movements of both arms were present, as well as occasional movements of the right leg. No significant increase in muscle tone was noted.

Reflexes: Tendon reflexes were 2+ in the upper extremities, 2+ at the right patella and 3+ at the left patella, and 2+ at the ankles. Plantar responses were flexor. There was normal anal wink and rectal tone. Superficial abdominal reflexes appeared diminished but present (difficult to fully assess due to body habitus).

Sensation: Slow withdrawal to painful stimuli was noted in all extremities, though noticeably more briskly in the arms. Facial grimace was noted with noxious stimuli applied to the extremities and the trunk.

Coordination: Unable to evaluate due to paucity of directed movement.

Gait: Unable to evaluate.

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