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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