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If you have completed case P, this is a review. Completion of this case will not be counted toward your assignment.
You are a primary care doctor with an office right across the street from a large community hospital where you have admitting privileges. It’s Monday morning and you just finished rounding on all your patients in the hospital. You’re sitting down to catch up on paper work when your nurse walks into your office and says Mr. Larry B. needs to be seen. Larry, despite being a difficult patient, is a terrifically fun guy and everyone is quite fond of him. You always look forward to seeing him on the rare occasions when he not only makes, but also keeps, an appointment. You went into an exam room to see what occasioned a visit from Larry and his wife, Ruth.
Larry, a 68 year old right-handed man was brought in by his wife who reported that "All of a sudden he dropped the coffee, his face sagged and now he can’t talk."
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Begins
2 hours ago when Larry and Ruth were having breakfast. Larry suddenly
dropped a cup of coffee from his right hand and Ruth noticed a right
facial droop. More strikingly, Larry, normally quite a chatterbox,
completely ceased speaking. He could grunt and say "hello," but
that was all. Ruth was understandably alarmed by Larry’s state and said
"we need to go see the doctor". Larry not only could
follow the commands given by his wife, but unlike his usual self, walk to
the car without further coercion.
Since the onset of the problem, Larry’s condition neither worsened nor remitted. There were no other symptoms around this time such as repetitive movements, or complaints of H/A, CP, or palpitations before the onset of symptoms. |
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PMH:
Significant for Hypertension, hypercholesteremia and type II DM. Larry is noncompliance on medication. Larry stated in the past, much to your disapproval, "I don’t like drugs and I don’t like doctors, you can give ‘em to me, but I don’t have to take ‘em." The patient’s wife recalls an episodic "mini-stroke" one year ago. Upon further questioning, we learn the patient presented with loss of vision in one eye lasting 15 minutes. Subsequently he was convinced to undergo a carotid endarterectomy for symptomatic carotid stenosis of 98%. Since that time, he has been lost to F/U. Allergies: NKDA |
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Meds:
HCTZ 25 mg PO qd, Captopril 50 mg PO bid, Glyburide 6 mg PO qAM, Zocor 20
mg qd and baby aspirin qd, but patient admits to taking it only when he
feels his blood pressure or blood sugar is high.
FH: Parents died of old age, has 2 sons and 1 daughter, all three in good health. SH: Lives with wife of 30 years who encourages patient to take meds and not take cigarettes. Unfortunately, the patient remains quite compliant on his pack per day habit of 50 years. He drinks 2 beers per day and does not take illicit drugs. He is a retired steel worker. Vital signs: Temp: 37.0, BP: 170/100, Pulse: 88, Resp: 20. |
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General
appearance: Obese patient, appears stated age, NAD.
HEENT: PERRL, EOMI, Left fundi with cholesterol (Hollenhorst) plaques, mucus membranes moist. Neck: No bruit bilaterally. No Jugular Venous Distension. Heart: RRR without murmur, rub, or gallop. Lungs: Clear to Auscultation B. Ab: Obese, Non-tender, non-distended, + B.S. Ext: No Cyanosis, clubbing, or edema. Neuro: Mental status: Alert. Pt. cannot repeat, cannot name, speech is restricted to word "hello." Follows commands appropriately. Pt. cannot write sentence, writes "Hello." Can copy figures. |
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Cranial
Nerves:
II right homonymous inferior quadrantanopia. III, IV, VI: EOMI V: facial sensation intact. VII: Right lower facial droop, flattened nasolabial fold. Wrinkles brow symmetrically. VIII: Hearing grossly intact. IX, X: gag intact, palate rises symmetrically. XI: shrugs symmetrically. XII: tongue midline. Motor: RUE 0/5 proximally and distally. RLE 4/5 proximally, 5/5 distally. All left extremities are 5/5 proximally and distally. Reflexes: No reflexes, RUE in all muscle groups. Otherwise 2/4 and symmetric with downgoing toes. Sensory: Pin, vibration, position tested. All slightly decreased in RUE. Otherwise preserved. Cerebellar function: nl. Finger to nose on L. Nl. Heel shin B. Gait: nl. Romberg: nl. |
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As
Larry is pretty stable, he was transferred urgently by car to the
emergency department at the hospital for further evaluation and treatment.
Labs: CT: wnl. Some evidence of cortical atrophy
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| After the patient received intravenous tPA and 24 hours later aspirin, a CXR, echo, and EKG failed to demonstrate any abnormalities. He was admitted to a telemetry monitoring section of the hospital and immediate consults to physical and speech therapy. A carotid duplex showed 90-99% proximal internal carotid artery stenosis on the left and 20% on the right. |
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