2005 Exam II Case 02

Chief Complaint:

A 40-year-old intoxicated, belligerent male was brought to the emergency department by ambulance after his wife called 9-1-1 reporting that he had fallen down the back steps and she couldn’t get him up. 

History of Chief Complaint:

His wife is present to provide a history and reports concern about continued consumption of large amounts of daily alcohol by her husband.  She states that he has exhibited personality changes recently including social withdrawal, depression, and sometimes verbal “explosions” toward her or their sons.  She also reports that she hears him “talking to himself” more than usual and describes him as “forgetful at times”.  She states that this new behavior started a few months before he was fired from his job as an assembly line worker at an automobile manufacturing plant.  Per company report, he was fired six months ago for not meeting production deadlines, multiple errors, and sloppy work.  His wife feels that his emotional outbursts may be to blame.  She does admit that he has been clumsy when working around the house.  She describes anxious behavior and “weird movements or jerks” in his arms and legs.  She blames his nerves, stress from financial troubles, and alcohol for this.  The patient denies the entire spouse report and screams repeatedly: “Women and doctors can’t be trusted!”  He has no primary care physician and is on no medications.    

Social History:

He is married with two sons; both away at a summer sports camp.  His wife is not able to provide much of a family history because he was adopted as a child.  She only notes that he has no known siblings.  She denies any tobacco or recreational drug use by her husband.  She approximated that, by her grocery bills, he has consumed anywhere from 7-15 beers a day since he stopped working.             

General Physical Examination:

The patient is obese, appears intoxicated and smells of alcohol.  A 4-cm abrasion is present on the right forearm with palmar cuts bilaterally.  A 4-in diameter contusion is present on the right knee along with a left shin hematoma.  All preliminary radiology reports are negative for fractures.  Exam of head reveals no signs of trauma or injury from fall.  Patient. denies headache or projectile vomiting.  Funduscopic exam reveals no evidence of exudate, hemorrhage, or papilledema.  Heart rate and respiratory rate are slightly elevated.  Blood pressure was 140/84.         

Neurological Examination:

Mental Status:  Patient. is awake but somewhat intoxicated.  He is oriented to self but not to time and place.  His speech is slurred and rambling; however no word substitution or word confusion is present.  Patient. is able to remember the fall and blames his balance, rather than alcohol, for the event.  He is irritable and states a dislike of hospitals and physicians.  With his wife’s coaxing, he agrees to be examined.   

Cranial Nerves:    A full range of eye movements and complete visual fields are present.    Pupillary reflexes are intact to both direct and consensual light.  An increased frequency of exaggerated blinking is noted in both eyes.  No excessive tearing to lacrimal gland stimulation is evident.  Hearing is intact to finger rub at both ears.  Corneal, jaw-jerk, and gag reflexes were intact.  Patient frequently grimaces, but is able to complete all facial movements voluntarily.  Uvula and tongue were midline.

Motor System:  Range of motion was full and pain-free throughout all extremities except flexion of right knee beyond 120 degrees secondary to anterior swelling from contusion.  Patient demonstrated 4+/5 strength throughout bilateral upper and lower extremities.  Finger-to-nose and other coordination tests were not conducted because of intoxication.  An apparent involuntary, jerky movement was noted at rest in all extremities.  Deep tendon reflex testing of pain-free extermities revealed a pendular resolve.  The patient demonstrated a writhing movement about his right wrist with occasional jerks of his right elbow.  He attempted to cover this involuntary movement by placing his right hand under his right thigh.  Writhing movements were also apparent in both lower extremities at rest with occasional jerky, purposeless foot movements.  The wife reports that the only time that he stops moving is when he is asleep or “passes out”.  

Sensory Exam:  Pain, temperature, vibratory sense, and proprioception sensations are intact throughout his body.

Questions

INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.