1997 Exam I Case 03

Chief Complaint:

This is a 58 year old right-handed male complaining of clumsiness, difficulty walking, dysphagia and dizziness.

History of Chief Complaint:

He has suffered intermittent headaches, dizziness and nausea for 12 hours prior to admission. Six hours prior to admission he tried bed rest to relieve the dizziness. When he awoke he found he had difficulty walking and could not operate the family car. At this time he called for assistance and was brought to the hospital.

Medical History:

He has a long standing history of hypertension for which his control is not consistent. For the past 5 years he has experienced leg pains, cramping, and rapid fatigue when walking which remitted on rest. He has also complained of a feeling of coldness in his hands and feet. Occasionally, on sitting or standing up rapidly, he has experienced dizziness.

Surgical History:

none

Allergies:

none

Medications:

Wytensin for the past 6 years.

Physical Exam:

He is an awake and oriented, overweight male. Blood pressure is 160/90, heart rate is 80 beats per minute, and respirations are 23 per minute; his temperature is 97.2°F and he is 5/9" and weighs 295 lbs. Peripheral pulses were trace at the wrists and absent at the ankles bilaterally. His hands and feet were cyanotic with +2 pitting edema present about the ankle. There was no cervical or inguinal lympadnopathy. His breathing is rapid and labored, however his lungs were clear to auscultation and abdomen was soft to palpation. He admits to nausea, diplopia, vertigo, dysphagia and dyspnea. He complains of a feeling that food, even liquids were sticking in his throat when he attempts to swallow. He also complains of persistent hiccup which began two hours prior to admission. His skin is moist and supple except over the left side of his face where it is dry to palpation.

Neurologic Exam:

Mental status: He is awake and oriented to time, person and place. His memory and fund of knowledge is intact. His speech is slightly dysarthric, his words are slurred but otherwise meaningful.

Cranial nerves: Visual fields are intact to confrontation and a full range of extraocular movements are present. A mild right beating nystagmus is present on forward gaze that became worse on right lateral gaze. He admits to slight diplopia and vertiginous sensation. Pupils are 3.5 mm on the right and 2 mm on the left; both are reactive to light. A diminished sensation to pinprick is present on the left side of his face from the left ear to the apex of the jaw. Otherwise sensation is present through his face. Corneal reflex is depressed in the left and present on the right. Gag reflex is present on the right and absent on the left. Facial expressions are symmetric. Power is intact in the sternocleidomastoid and trapezius muscles.

Motor exam: All extremities are motionless at rest. Power is intact in all four extremities. Finger-to-nose and heel-to-shin tests are normal on the right but uncoordinated on the left. He could not perform rapid alternating hand movements or rapid finger tapping on the left, but these movements are normal on the right. He veers to the left when attempting gait and is unstable. Heel-to-toe walking is not possible due to the difficulty he experienced when attempting to balance on his left foot.

Reflexes: Deep tendon reflexes are intact and normal in all four extremities.

Sensory: Position sense and 2-point discrimination are intact throughout his body. Response to pinprick is present on the left side of his body but greatly diminished on the right in his body and extremities.

Questions

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