History and Physical — Patient 82

History

Present Illness: Patient is a 55 year old White woman who was evaluated in the ER at the Veterans Affairs Medical Center with a one week history of dizziness, sometimes leading to falls. Upon further questioning, her son corrected that she had been unsteady for several months. She felt that the dizziness worsens with changing of position from supine to standing. There was also enhancement of her dizziness with swift movement in one way or the other. She described extreme unsteadiness, even to the point that if her dog bumps into her she will fall. She described her gait as shuffling and feels unsteady. She stated that she has been drinking heavily lately because of her medical situation and worsened depression. She had been taking a number of pain medications due to abdominal pain following renal surgery a couple of months prior to admission. She denied vertigo, nausea, nor vomiting. There were no changes in her vision, tinnitus, nor changes in her ability to hear. She denied any sensory changes or bowel/bladder incontinence.

Past Medical History: Hypertension, asthma, depression, gastric ulcer, and right ovarian cyst. She had been a heavy alcohol abuser, ever since her husband died several years before presentation. This extensive abuse had been medically complicated by pancreatitis. She did cut down on alcohol intake after her diagnosis of pancreatitis, but had recently started back abusing alcohol because of depression. She admitted that she has recently been drinking 5-6 drinks per day. She had been treated for DT's in the past.

Past Surgical History: Hysterectomy, C-section, right nephrectomy and partial left nephrectomy 11 years apart for some suspected mass lesion.

Medications: Sertraline, hydrochlorothiazide, lisinopril, ranitidine, APAP/butalbital/caffeine, albuterol, ipratropium, verapamil, and estrogen replacement.

Family History: Significant for diabetes mellitus, hypertension, a paternal Grandmother who died of pancreatic cancer, a sister with brain vascular malformation. She also has a daughter who was given up for adoption, and therefore was unavailable for questioning of medical history.

Social History: In addition to alcohol abuse, she also has smoked tobacco at about 1 pk/day for 38 years. She denied abuse of other illicit drugs. She was a nurse and has had increased depression since the death of her husband. She denied suicidal or homicidal ideations.

Review of Systems: She denied chest pain, gastrointestinal symptoms, nor focal weakness and sensory changes. She described some exertional shortness of breath, 40 lbs weight loss in the past year, some slurring of speech, mild headaches for the past several weeks, intermittent blurring of vision, as well as some depressive symptoms.

Physical Exam

General: Well developed, well nourished female, who appears to be in no apparent distress.

Vital Signs: Blood pressure: 115/76; pulse: 105; respiration: 20; temperature: 98; weight: 145 lbs.

Neck: Supple, no bruits

Chest: Clear to auscultation bilaterally.

Cardiovascular: Regular heart rate and rhythm, no murmurs.

Abdomen: Positive bowel sounds, soft, nontender/nondistended, bilateral abdominal nephrectomy scars.

Extremities: No edema, positive dorsalis pedis pulse bilaterally.

Rectal: Guaiac negative, normal sphincter tone.

Neurological Examination

Mental Status: Alert and oriented x 4, no difficulties with comprehension and repetition.

Cranial Nerves:

Cranial Nerves

Findings

II, III, IV, VINo papillary abnormalities, extraocular movements intact, no visual field deficits.
VGood sensation to light touch and pin prick at V1, V2, V3.
VIIMild left lower facial droop.
VIIIHearing grossly intact bilaterally.
IX, XNo dysarthria, palate elevates evenly.
XIGood strength of bilateral sternocleidomastoid and shoulder shrug.
XIITongue midline.

 

Motor:

Strength

Right

Left

Upper Extremities

  
Deltoid4+4+
Biceps4+4+
Triceps55
Wrist Extensors44
Wrist Flexors55
Finger Extensors55
Finger Flexors55
Hand Intrinsics55

Lower Extremities

  
Iliopsoas44
Knee Extensors55
Knee Flexors44
Ankle Extensors55
Ankle Flexors55

 

Reflexes:

Reflexes

Right

Left

Biceps3+3+
Triceps3+3+
Brachioradialis3+3+
Patellar3+3+
Ankle3+4+ (4 beats)

 

Positive Hoffman bilaterally, negative Jaw jerk, positive Glabellar sign, and withdrawal response to Babinski exam.

Sensation: Romberg sign present. Intact to light touch, vibration sense, and proprioception. Intact cervical position sense. No graphesthesias, no sensory level.

Gait: Wide based, magnetic gait, reached for support throughout gait exam.

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