Massachusetts Institute of Technology
Tim Wagner
Patient: “Ms. M”
CC: “spasms at night in her right leg, feels like it’s jumping”
HPI:
The patient is a 86 year-old woman who is a bit demented and very hard of hearing thus making for a poor historian who presented with middle to upper radiating right leg pain and upon examination proved to be remarkable for painful urination. She has a past medical history remarkable for UTIs, HTN, MIs (2x), anemia, and a left femur and hip fracture subsequent to a fall. She was admitted via the MAH ER last Thursday (1/22/04) after a phone consultation with her PCP, Dr. DeSimone, for her RLE pain. For the past month she has awoken from sleep during the night multiple times with spasms in her leg that start in the posterior region of her knee and radiate upwards into her groin and hip region. She characterizes the spasms as “non-painful”, but during the physical exam experienced one that elicited a painful response, so it was difficult to characterize her pain. She has no lower leg sensory loss, no burning sensation, no feeling of pins and needles, and 5/5 strength in the lower extremities. Although she claimed that the pain was not elicited by movement or increased activity she seemed to experience the spasms upon movement (both of the upper body and right lower extremity). There was no indication of trauma, rash, or scarring on the leg below the knee but the upper region was not assessed due to the exam room situation and for the patient’s comfort. According to her intern the leg injury is subsequent to a fall but the patient was less definitive about the root of the leg problem during the interview.
Upon admittance it was discovered that the patient had a UTI. She characterized her urination pain as a 1 out 10 and as very mild and that she became aware of the pain approximately one week ago when she was told that she was suffering from a UTI. She indicated that her frequency of urination was not increased, her urgency to urinate was not increased, and that the color of the urine was unchanged. She reported to be afebrile and without flank pain.
PMH (primarily derived from charts, patient was primarily unaware of their medical history):
1. Anemic, unknown duration
2. Depression, unknown duration
3. Parkinson’s, unknown duration
4. 2 x MI (one on 1/01; nontransmural; other unknown date), 1st degree heart block
5. HTN
6. LVH, unknown diagnosis date
7. Pneumonia
8. Renal Insufficiency
9. Glaucoma, unknown duration
PSH:
1. TAH, unknown date
2. Hip/ femur repair 2001
3. Cataract Surgery, OU, unknown dates
PGH:
2 Births, unknown pregnancy miscarriage
PPH:
depression
Medications:
Atenolol 25mg PO QD
Paxil 10mg PO QD
Norvasc 10mg PO QD
ASA 81mg PO QD
HCTZ 25mg PO QD
Allopurinol 100mg PO QD
Pilocarpine 4% OU qhs
Ciprofloxin 250mg PO QD
Sinemet 10/100mg PO QD
Pecrucet 1 tab PO QD
Hydroconone 1 tab PO QID
Tylenol 650 mg PO QH6 PRN
Trazapnol 25mg PO QH6 PRN
Vicodin 5/500mg PO QH6 PRN
Family History:
She has two daughters, 57 and 59. Her other history was non-contributory.
Social History:
The patient has lived in the Boston area her entire life. She currently lives at home with her daughter. Her other history was non-contributory.
Review of Systems:
General gained weight over past month, claims general fatigue over last week in hospital
Skin denies rashes, itching, dryness
Head denies any dizziness, headaches, or syncope
Eyes +eyeglasses, glaucoma hx
denies double vision, loss of vision
Ears nearly deaf (sensoneural)AU, more severe AS
denies tittinus, vertigo, earaches
Nose + increased discharge over week in hospital
Mouth + dentures
Neck + denies neck stiffness, nodules, or thyromegaly
Respiratory +dyspnea, wheezing
Cardiac +history of HBP,LVH, 1st degree heart block,
denies palpitations (once over past few months), denies chest pain
Gastrointestinal denies diarrhea, GI pain
Urinary denies increased frequency or urgency of urination, denies dysuria
+ hx of UTIs
Musculoskeletal denies any upper body joint pain or stiffnes
+lower R leg pain, denies L leg pain
Neurologic Denies numbness, blackouts, or dizziness
Hematologic +anemia
Physical Exam
General questionably alert and oriented elderly woman, difficult to converse with (deafness and possible slight dimensia), frail on appearance
Vital Signs temp 98; BP 130/80; Pulse 102; RR 20; O2Sat 95 % on RA
Head normocephalic, atraumatic
Eyes pupils equal and round, fundi difficult to visualize, OU not reactive to light and absent for pupilary light reflex
Ears tympanic membrane not visualized, poor hearing AD and just slightly improved AS
Nose no current sinus tenderness
Orophanyx not examined
Neck no thyromegaly, or altered thyroid texture
No nodules or tenderness
Back not examined
Lungs normal chest diameter, bilaterally symmetric expansion, bilaterally clear to auscultation; no wheezes, rhales, or rhonci
Cardiovascular irregular rate (went from around 60 to 102 rate during exam) normal rhythm; S1 S2 heard both early syastolic, pseudo crescendo decrescnedo +2 mummur indicative or aortic stenosis and a holosyastolic +2 mumur indicative of mitral regurgitation; no rubs or gallops; S3 and S4 not heard; no bruits; no jugular venous distension; PMI not appreciated
Abdomen normal bowel sounds but the remainder was not examined
Rectal Not examined
Neuro CN1 responds to smell
CN2 Fundi difficult to visualize
Peripheral field intact
OU not responsive to light
CN2/CN3 OU pupillary reflex absent
CN3,CN4,CN6 EOM in 6 directions without nystagmous
CN5 Motor normal
Sensation in all three fields bilaterally
CN7 Motor Normal
Sensory not tested
CN8 Lateralization bilaterally normal by Webber test
Conduction normal by Rhinne AU
Severe Sensoneural hearing loss AD, and some in AS
CN9/CN10 Swallowing normal
CN11 Sternocladomastoid and trapezious 5/5 strength
CN12 tongue movement 5/5 with no atrophy
Cerebellum not tested for RAM, PPM, or stance; observed gait (assisted by PT and walker) and no abnormalities appreciated
DTR not examined
Motor Strength Upper: forearm flexion 5/5:
forearm extension 5/5
wrist extension 5/5
hand grip not tested
finger abduction 5/5
thumb opposition 5/5
Lower hip flexion:5/5
hip extension: 5/5
hip adduction: 5/5
hip abduction: 5/5
knee flexion: not examined
knee extension: not examined
ankle dorsiflexion:5/5
ankle plantar flexion: 5/5
Sensory Pain and temp:
Dermatones in tact and responsive to cold
Light touch: not examined
Position and vibration: in tact in lower extremities
Discriminative Sensation: not examined
A tardi dyskinesia was noted on the second exam of the patient, the rhythmic opening and closing of her mouth was apparent throughout the entire second exam (10-15 minutes) but not appreciated throughout the entire first exam (1 hour and 15 minutes).
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