History and Physical — Patient 89

History

Present Illness: Patient is a 58 year old right handed woman, previously high functioning and without known psychiatric disorder, who presented to the emergency room with apparent paranoia. She had accused her husband of poisoning her and causing her symptoms. The patient also refused to go back home with her husband and broke the window at her friend's house. Moreover, she developed visual hallucinations, seeing cockroaches and butterflies in her room.

Upon admission, the patient's functionality quickly deteriorated as she developed severe apraxia and akinetic mutism within a week, such that a PEG tube placement became indicated. She also developed isolated jerk movements of both hands (synchronous or asynchronous), which can occur either spontaneously or upon verbal or physical startle.

The patient was recently admitted just one week ago for multiple symptoms including visual changes (tunnel vision, blurry vision, and floater), cognitive difficulties (short-term memory and visual spatial deficits), motor symptoms (difficulty walking, swallowing, and enunciating words). Family first noticed this constellation of symptoms about six weeks ago, and endorsed that symptoms have notably worsened over the past 10 days. She was previously highly functioning. However, symptoms progressed to the point that she was no longer able to independently provide self-care or ambulate. During this earlier admission, patient had completed a full work-up for infectious, autoimmune, vascular, metabolic and paraneoplastic causes. The work-up included lumbar puncture, brain MRI with and without contrast, whole body CT, autoimmune/metabolic labs, CT-Angiogram of head and neck. All of these tests were non-revealing, except for pending paraneoplastic evaluation results.

Review of Systems:

  • Constitutional: No fevers, no chills, 10 lbs. unintentional weight loss x two months, positive for night sweat.
  • HEENT: Positive for post-nasal drip, no rhinorrhea, no sore throat, no read eyes.
  • Pulmonary: No chest pain, no SOB, positive for dry cough.
  • Cardiac: No chest pain, no heart palpitation, no edema.
  • GI: No abdominal pain, no diarrhea, no constipation or melena.
  • GU: Positive dysuria, no hematuria, no oliguria, no polyuria.
  • Musculoskeletal: No joint pain, no myalgias, no swelling.
  • Endocrine: No history of diabetes, no thyroid disease, no hot/cold intolerance.
  • Hematology: No easy bleeding.
  • Skin: Positive for psoriasis.
  • Neuro: See HPI.

Past Medical History: Psoriasis and hypertension.

Past Surgical History: Knee surgery "a long time ago." Breast reduction surgery 25 years ago.

Family History: Mother with DM.

Social History: Denies alcohol, tobacco, or any illicit drug abuse. Lives with husband, and she has four dogs, two cats and one parrot. She worked as a dog trainer prior to presentation. No recent travel, sick exposure.

Medications: Lisinopril 5 mg once a day.

Physical Exam

Vital Signs: BP 124/74, T= 98.2, HR=68, RR=19, O2 sat 99% on room air.

General: No apparent distress.

HEENT: Normocephalic, atraumatic, with mucous membranes moist.

Neck: Supple, No palpable lymphadenopathy, no bruits heard, no stiffness.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Normal cardiac rate, rhythm, normal heart sounds.

Abdomen: No organomeglay, soft, NT, ND.

Musculoskeletal: Full range of joint motion, without pain.

Extremities: No cyanosis, edema or skin lesions.

Spine: No midline defects.

Neurological Examination

Mental Status: Alert, awake, oriented to self, place, time and situation. However, the patient was paranoid about her family members and stated that people were trying to poison her.

Speech: Fluent, no errors in comprehension, naming or repletion.

Cranial Nerves:

Cranial Nerves

Findings

INot tested
II / III / IV / VIPERRL, EOMI, no peripheral field cut
VNormal sensation in v1-v3 distribution, temporalis and masseter strength normal symmetrically
VIINo facial droop noted
VIIIHearing intact
IX / XUvula elevates
XINormal strength of SCM and trapezius bilaterally
XIITongue midline

 

Motor: Tone normal in all extremities; 5/5 throughout.

Reflexes: 2+ throughout, down-going toes bilaterally.

Sensation: Intact to light touch, pinprick throughout, intact proprioception and vibration.

Cerebellar: Positive intentional tremor on FTN worse on L, HTS is ataxic on L > R.

Gait: Wide base and unsteady.

Romberg: Positive with swaying.

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