History and Physical — Patient 79

History

Chief Complaint: Confusion and difficulty walking

Present Illness: The patient is a 27 year-old, left handed Caucasian male, previously in good health, who developed the acute onset of nausea, vomiting, and loss of balance during a family trip to Galveston, Texas. By the following morning, the patient continued to have nausea and vomiting, and he was not able to stand. He was then taken by his family to a local emergency room. After evaluation with a CT scan of the head and lumbar puncture, he was admitted to the local hospital for further treatment. During this hospitalization, he received several days of treatment with intravenous methylprednisolone. He experienced partial resolution of his symptoms and was discharged on a tapering dose of oral methylprednisolone.

Approximately ten days after discharge, the patient experienced worsening of his unsteady gait, together with short-term memory loss and headache. He became quite confused and listless, and exhibited unusual behavior. For instance, the patient's wife reported that he began ringing the doorbell to their house at 1:30 a.m. He was taken to a hospital close to his home town and admitted for further evaluation. After receiving several additional treatments with intravenous methylprednisolone, he was transferred at the request of his family to the Methodist Hospital in Houston, Texas.

Past Medical History: No prior illnesses. No hospitalizations before the present illness.

Past Surgical History: Endodontic procedures at age 17 and again at six months prior to admission.

Allergies: No known drug allergies.

Medications: Intravenous methylprednisolone; intravenous 5% dextrose solution. No medications were taken at home.

Social History: The patient worked at a water treatment plant for one to one and a half years, and during this time was reportedly exposed to aluminum sulfate, mercury and silver. For the year prior to hospitalization, he worked in a pest control business, with reported exposure to permethrin. There were no identified sick contacts, and no other identified toxin exposures. He had no history of foreign travel. There was no history of tick bites or outdoor activities in the recent past. He consumed no more than one to two drinks of alcohol on social occasions. There was no history of smoking or intravenous drug use. The patient lives with his wife of two years.

Family History: The patient's mother and father are healthy. Hypertension, diabetes, stroke and myocardial infarction were present in family members on his mother's side. His maternal grandfather had beryllium exposure. Hypertension was present in family members on his father's side. No history of neurological disease or rheumatic disorders exists on either side of his family.

Review of Systems: General: The patient reported recent, intentional ten pound weight loss. No fevers or chills were reported. HEENT and Neurological: The patient reported no blurry vision or double vision. He has suffered from chronic daily headaches for the last two to three months. He reported two weeks of hearing loss in the right ear, accompanied by bilateral tinnitus; previously his hearing was intact. He said that he had no difficulty swallowing or speaking. He reported memory loss. Currently, he uses a walker for assistance with ambulation, due to his gait unsteadiness. Skin: No rashes or hair loss reported. Joints: Patient denies joint pain or swelling. All Other Systems: Otherwise unremarkable.

Physical Exam

General: The patient is a young, alert, pleasant male in no acute distress. He is well-developed and well-nourished.

Vital Signs: BP: 133/88 mmHg. Pulse: 104/min. Respirations: 12/min. Temperature: 97.1 degrees Fahrenheit. Weight: 230 pounds.

HEENT: Normocephalic, no evidence of trauma. Mucous membranes are moist; oropharynx is clear. Temporal pulses were present and normal. Examination of the external ear and canal was normal. The neck was supple without lymphadenopathy.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Tachycardia without murmurs or rubs.

Abdomen: Soft, nontender without hepatosplenomegaly.

Extremities: No cyanosis, clubbing or edema present in the extremities. No joint pain, swelling or restriction of range of motion. Peripheral pulses were normal and symmetric.

Skin: Clean, dry and warm. Acne is present on his back, but otherwise no lesions or rashes are present.

Neurological Examination

Mental Status: The patient was oriented fully to person and time, but not to place. He named the city and state, but not the county, hospital or floor of the hospital. Folstein Mini-Mental Status examination score was 25 of 30. He missed one point for word recall, one for the copying diagram task and one for a sentence writing task. He had good repetition and registration, but great difficulty with proverb interpretation and sentence writing. He exhibited slowing of speech production.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIVisual acuity was 20/20 bilaterally, without visual field deficits identified by confrontation testing. Funduscopic examination revealed sharp disc margins bilaterally. Cotton-wool spots were visible in both fundi, more pronounced on the left.
III / IV / VIExtraocular movements were full without nystagmus. The patient did not exhibit ptosis.
VSensation was intact in all sensory distributions of the trigeminal nerve. Strength of muscles of mastication was normal.
VIIStrength of facial musculature was intact bilaterally. Taste sensation was normal in the anterior two-thirds of his tongue.
VIIIHearing was markedly decreased in the right ear to whisper and finger rubs. Reporting on Weber testing was inconsistent.
IX / XGag reflex was normal, with normal sensation at the palate. Palate elevates at midline.
XISternocleidomastoid and trapezius strength normal bilaterally.
XIITongue protruded in the midline without atrophy or fibrillations.

 

Motor: The patient demonstrated normal bulk and tone in all four limbs. He had 5/5 strength in all four limbs.

Reflexes: He exhibited very brisk, 3+ reflexes with spread at biceps, triceps and brachioradialis on both sides. Reflexes were slightly more brisk but still 3+ at both knees. The right Achilles reflex was 4+ with four beats of non-sustained clonus at the right ankle. The left Achilles reflex was 3+. Plantar responses were flexor bilaterally.

Sensation: Sensory examination was intact to fine touch, proprioception, vibration, temperature, pinprick, and pain in all four limbs.

Coordination: He exhibited truncal ataxia with titubation. He had dysmetria with finger-nose-finger and heel to shin testing bilaterally. The rate and accuracy of rapid alternating movements was decreased bilaterally.

Gait: He exhibited a wide-based and ataxic gait, and tended to fall to the right.

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