Neurology Case Studies

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT

Trouble talking.

HISTORY OF PRESENT ILLNESS

This patient tells me that he was awakened with inability to speak.  He had a slurred voice, and saliva drooled from the right corner of his mouth, and he had some tingling and weakness in his right arm and right leg.  This seemed to improve over the succeeding 3 or 4 weeks, and he was getting along a little better until last night when he began having some jerking movements in his left arm, and this morning he had some more slurring in his speech.  He was extremely weak.  It was hard for him to walk, and he is now admitted for recent stroke syndrome.

REVIEW BY SYSTEMS

No headaches.  Hearing decreased.  Blurred vision, particularly in the right eye.  It is hard for him to focus, read, and watch television.  Cataracts with implants have been done bilaterally.  His bowels have been quite good, but they have been black due to iron that he has been taking.  Nocturia 1 time.  He is on potassium, Tenormin, and water pills.  In addition to the arteriosclerotic problems, he was found to have pernicious anemia about a year ago with a very low B12 level in the blood.

PHYSICAL EXAMINATION

VITAL SIGNS:  The physical exam reveals a blood pressure of 140/70, pulse 68 to 70.

GENERAL:  Skin is very dry.  The rhythm of the heart is sinus.  He was very slow mentation, and his attention span is not long.  There is slurring of speech, but there is no unilateral paralysis.

CHEST:  His chest is clear.

HEART:  His heart tones are fair.  The heart is at the upper limits of normal, and there is a systolic murmur over the apex.

ABDOMEN:  His abdomen is obese.  No masses can be felt.  He has a large right inguinal hernia, and he wears a truss.

RECTAL:  Prostate is enlarged 2+.  Gland is smooth.  Stool negative for blood.  No masses in the rectum.

EXTREMITIES:  There is 1+ pitting edema in the legs, and he has moderate varicose veins.  His reflexes are slightly hyperactive on the right side.

DIAGNOSES

1. Cerebral arteriosclerosis.

2. An old stroke and possibly a more recent one.

3. Carotid artery plaquing with questionable stenosis.

4. Pernicious anemia, treated with B12.

5. Right inguinal hernia.

6. Congestive heart failure secondary to arteriosclerotic heart disease.

FOOTNOTE

Line 31 (Page 1).  Exam was expanded in the heading.

Line 33 (Page 1).  Alternative:  68-70.

Lines 32-47 (Page 1).  Some subheadings were added for clarity.

Lines 50 (Page 1)-6 (Page 2).  The diagnoses were enumerated.