Term 3 Sample Write Up

Identifying Information / Chief Concern:

CP is a 73yo women with a distant history of a stroke who presents with acute onset of bilateral finger numbness and tingling progressing to proximal arms and distal feet over the past 2 months.

History of Present Illness:

Eight weeks ago, CP and her partner visited their daughter in Arizona after disembarking from a cruise in Houston. That day, CP reports tingling and numbness in all her fingers bilaterally. Over the next few days, CP reports that the numbness and tingling progressed to include her entire hands plus a burning sensation. Her symptoms were especially noticeable when trying to write, which she no longer could do, because she could not figure out how much pressure to apply to grab items.

Three days later, CP and her partner returned home to X, and she visited her PCP for these symptoms. She was hospitalized and evaluated for Guillain-Barré syndrome given the ascending numbness and Valley Fever given her recent travel to Arizona. A CT and MRI of her brain and lower back was performed; her brain was normal, and her lower back showed arthritis in L5-L6 which CP plans to address in the future. CP denied a spinal tap, but blood work came back positive for Hepatitis A. With no immediate findings, CP was discharged from the hospital three days after being admitted. Over the course of the first week, the numbness, tingling, and burning had progressed to include her fingers, hands, and now her toes and feet.

Six weeks ago, an EMG demonstrated normal functioning musculature. Despite a normal EMG and brain imaging, the numbness and tingling in her feet has required her to use a walker to aid in walking as gauging the feeling of pressure necessary to walk was extremely difficult for CP.

For about the past month CP reports worsening weakness and fatigue plus difficulty concentrating and memory. She was evaluated by a neurologist for dementia and Parkinson’s, whose report came back with no abnormalities.

Four weeks ago, CP had been seeing her chiropractor who urged her to see her physician after reporting worsening stiffness in her neck. Her PCP ordered an MRI of her neck which identified a C3/4 herniated disc. For this, an anterior cervical discectomy was scheduled. CP stopped taking analgesics three weeks ago in preparation for this surgery.

In the past week, CP reports difficulty baring down to have a bowel movement, unable to engage the full strength of her musculature. She reports no difficulty urinating or dysuria. Over the course of the past eight weeks, the numbness, tingling, and burning has gradually ascended bilaterally up to her shoulders and knees.

She does not report difficulty breathing, shortness of breath, difficulty swallowing or eating. She had no inciting traumatic injury or fall. No history of cancer. No history of IV drug use. CP reports no recent illnesses, fever, diarrhea, or nausea. She does continue to report abdominal sensitivity, but she has experienced this for years. This sensitivity, CP reports, is a skin pain around her abdomen that feels like a “cinching string” that she has had for years. Pt has no saddle numbness. Eating and OTC analgesics help alleviate the pain.

One day ago, CP was admitted to the hospital and had an anterior cervical discectomy of C3/4 using cadaver bone for this herniation. Since yesterday’s procedure, CP has been resumed her ibuprofen, acetaminophen, and gabapentin which she says has significantly improved her level of pain. However, her hands are still swollen and burning with pain, and she has difficulty grabbing items with her hands and walking.

Hospital Course:

For recovery, CP is working with physical therapy to improve her stability and walking. She will be discharged once she can safely walk unassisted.

Past Medical History:

Major Childhood Illnesses:
Asthma

Adult Medical Conditions:

• Stroke – diagnosed 2016 incidentally with MRI during work up for restless leg syndrome
• Restless leg syndrome – 2016
• Prediabetic – date of diagnosis unknown
• Herpes Simplex Virus II – 1980. treated with valacyclovir for flare ups
• MVA polytrauma – 1983
• Ovarian cysts – 1974 treatment via cystectomy
• Endometriosis – 1975 treatment via hysterectomy
• Hard of hearing from eardrum damage – Has hearing aids, but hoping to schedule
  appointment for cochlear implants soon.

Past Surgical History:

• Cataracts (bilateral) – 2023
• Left heel repair (stepped on nail) – 2022
• Ambulatory phlebectomy – 2010
• Left eardrum repair – 2003
• Hysterectomy (for severe endometriosis) – 1985
• Right ovarian cystectomy – 1974

Medications:

Outpatient:
Gabapentin PO QAM, TID HS – started 2016 (for pain)
Atorvastatin PO QD – start date not asked
Valacyclovir PO PRN (for HSV flare up)
Valium PO PRN (rarely used, has taken once in the past year)
Albuterol inhaler PRN (rarely used)
Fish oil PO QD
Calcium PO QD
Multivitamin PO QD
Vitamin D3 PO QD
Acetaminophen PO 3000mg PRN
Ibuprofen PO 2000mg PRN

Inpatient:
Acyclovir IV (reason unknown, potentially to treat Hepatitis A diagnosis?)
Cefazolin IV (reason unknown, potentially as prophylactic post-surgery?)
Senna stool softener PO

Allergies to medications:

Sulfonamides – rash (severity not asked)

Family History:

-Paternal history unknown
-Mother – stomach cancer (deceased at 30 yo)
-Maternal uncle – lung cancer (age at diagnosis not asked)
-Maternal uncle – bone cancer (age at diagnosis not asked)
-Sister – breast cancer (age at diagnosis not asked)
-Daughter – Stage 3 breast cancer (diagnosed at 40yo)
-Diabetes Mellitus: Brother, sister, maternal uncle, maternal grandmother

Health Related Behaviors:

Exercise: Active, walks and gardens regularly
Diet: Balanced, enjoys salads and meats
Tobacco: 20 pack year smoking history. Has not smoked in 20+ years.
Alcohol: Pt reports that she does not drink.
Drugs: Pt reports that she does not use drugs.
Sexual History: Not asked.

Social History:

CP was born in the Seattle area. She lived in X (other state) for decades and moved back to X in the 90s. She and her partner share their time between their homes in X which CP’s partner built, and X (other state). CP and her partner will be celebrating their 45the wedding anniversary this year. CP has 4 daughters and 10 grandchildren. One of her granddaughters (and her dog) recently moved into their house with them while she attends college down the road in X. CP is very happy to have her granddaughter living with her. CP is retired after working many years and many jobs in marketing. She and her partner are enjoying their retirement by sharing their time between X and X (other state) taking trips to visit their family throughout the country and going on cruises. CP is very involved with her community and spends her time gardening and volunteering.

Review of Systems:

-Constitutional: Entire body in pain and fatigued.
-Eyes: No vision changes, including no blurry vision or vision loss.
-Ears: Hard of hearing. See Past Medical History.
-Pulmonary: No cough, SOB, orthopnea or PND
-Cardiovascular: No Chest pain. No palpitations.
-Gastrointestinal: See HPI. No bloody stool.
-Genitourinary: No dysuria, increased frequency, urgency. See HPI regarding some difficulty with urination.
-Musculoskeletal: No joint swelling or redness
-Heme: No history of easy or prolonged bleeding
-Neuro: See HPI
-Skin: See HPI
-Psychiatric: No history of anxiety or depression.

Physical Exam:

General appearance: CP is sitting in a chair and moving is painful. Talking is tiring.
-Vital signs: BP 142/80. 80 BPM. Respiratory rate, spO2, and temperature not examined.
-HEENT: scalp: no tenderness or lesions. Facial sensations intact. No tenderness of facial sinuses
or mastoid. eyes: Visual acuity not tested. Red reflex present bilaterally. Symmetric corneal light
reflex. Conjunctiva moist and pale. Sclera white. Pupils equal, round, and consensually reactive
to light. ears: Hard of hearing even while wearing hearing aids. She relies on reading lips.
nose: External nose symmetric, free of lesions. No lesions or drainage of nares.
mouth/throat: Gums pink, no lesions in mouth. Throat free of erythema. TMJ and
muscles of mastication normal.
-Neck: Carotid arteries +2 bilaterally, no carotid bruits. Thyroid symmetric, non-tender. No
cervical lymphadenopathy, trachea midline.
-Chest: Breathes without difficulty. Breath sounds clear bilaterally without wheezes, crackles,
rubs.
-Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs, gallops or rubs.
JVP not appreciated. Extremity pulses +2.
-Abdomen: non-distended, bowel sounds present. Tenderness to palpation in LUQ and RLQ. No masses felt. Spleen not felt. No hepatomegaly.
-Skin: Warm and dry. No lesions or bruises. Bilateral swelling of hands, especially right hand,
with blanching erythema.
-MSK: Swelling bilaterally in hands and fingers, especially right hand. Extremities symmetrical.
Lower extremity edema absent.

ROM decreased in upper > lower extremities due to pain.
Difficulty grasping items by hand.

Motor strength:
RUE: 4/5 wrist flexion, 4/5 wrist extension
4/5 triceps extension, 4/5 bicep flexion

LUE: 4/5 wrist flexion, 4/5 wrist extension
4/5 triceps extension, 4/5 bicep flexion

RLE: 5/5 hip flexion, 4/5 hip abductors, 4/5 hip adductors
4/5 knee flexion, 4/5 knee extension
4/5 plantar flexion, 4/5 dorsal flexion
4/5 foot inversion, 4/5 foot eversion

LLE: 5/5 hip flexion, 4/5 hip abductors, 4/5 hip adductors
4/5 knee flexion, 4/5 knee extension
4/5 plantar flexion, 4/5 dorsal flexion
4/5 foot inversion, 4/5 foot eversion

Deep tendon reflexes:
3+ bilateral triceps reflex
3+ bilateral bicep reflex
3+ bilateral brachioradialis reflex
3+ bilateral patellar reflex
3+ bilateral Achilles reflex
Babinski: positive in right foot, negative in left

-Neurologic: Mental status: oriented to self and place

Cranial nerves:
CN II: not performed.
CN III/IV/VI: Extra-ocular eye movements intact bilaterally
CN V: Equal facial sensation and masseter strength.
CN VII: Muscles of facial expression symmetric.
CN VIII: Not responsive to rubbing fingers bilaterally nor speaking voice.
CN IX/X: Equal palate rise upon phonation.
CN XI: Head rotation and shoulder elevation not evaluated given s/p one day
neck surgery
CN XII: Tongue protrudes midline.

Cerebellar function: Finger to nose intact bilaterally. Heel to shin not checked.
Gait: Not examined given high fall risk.

Sensation: Sensation intact to light touch bilaterally on face, arms, legs and feet except absent sensation to touch on left hand 3rd and 4th digit.

Assessment and Plan

CP is a 73-year-old with a distant history of a stroke, recent travel to Arizona, and an incidental finding of Hepatitis A during the work-up for her presenting symptoms of numbness and tingling starting in bilateral hands and progressing to bilateral upper arms, feet and legs over the past 8 weeks. Physical exam remarkable for hyperreflexia throughout upper and lower extremities, distal motor weakness in upper and lower extremities. Differential diagnosis includes cervical myelopathy, Guillain-Barre syndrome and Chronic Inflammatory Demyelinating Neuropathy.

1. Bilaterally upper and lower extremity weakness, numbness and tingling:

The most likely diagnosis for CP is cervical myelopathy. CP’s age and history of smoking are risk factors for the development of osteoarthritis and disc herniation. The acute onset of the symptoms of numbness and tingling in the neck, arms, and hands is consistent with cervical stenosis and myelopathy. The bilateral nature of her symptoms along with bilateral upper and lower extremity muscle weakness and hyperreflexia supports a diagnosis of cord involvement. An MRI of the neck was performed to support this diagnosis.

A can’t miss diagnosis is Guillain-Barre syndrome. GBS generally presents with progressive and symmetric muscle weakness and is often associated with paresthesia. GBS is often associated with recent viral illness or immunization. CPs recent diagnosis of Hepatitis A may increase her risk of GBS; however, she had no other signs of recent viral illness or recent immunizations. A classic finding of GBS is symmetric weakness associated with decreased or absent tendon reflexes. CP had diffuse hyperreflexia not hyporeflexia. Also, her recent EMG and nerve conduction studies did not support a diagnosis of GBS. A cerebrospinal fluid analysis would help rule out GBS. A CSF consistent with GBS would be normal white blood cell count and elevated protein levels.

Another possible diagnosis, but less likely, is chronic inflammatory demyelinating neuropathy (CIDN). This condition generally presents with a relapsing-remitting or progressive course of symmetric proximal and distal muscle weakness. Usually, CIDN occurs over months to years and is more common in men which makes this less likely for our patient. Also, prominent sensory findings (sensory ataxia and impaired vibration and pinprick) on exam favor CIND. Our patient reported numbness and tingling but sensory findings on exam were minimal (I would go back and check vibration and pin prick on this patient). EMG and nerve conduction studies, CSF analysis and nerve biopsy (potentially showing segmental demyelination) could be helpful in evaluating for this diagnosis.

As for a plan, the next steps are dependent on the recovery course of CP from her cervical
spinal surgery (anterior cervical discectomy of C3/4). If her symptoms improve, no further workup is necessary. She should continue to attend her follow-up appointments with her surgeon and PCP. She should finish her course of antibiotics and antiviral medication (unclear why she is on these 2 medications). She should continue her physical therapy regimen to improve her stability and strength walking. However, if her symptoms do not improve, I would suggest a nerve biopsy, reapproach the conversation of a CSF analysis which CP initially chose not to undergo and a peripheral nerve ultrasound to identify other potential causes of her paresthesia.

2. Hepatitis A infection. Need to further explore possible exposures to Hepatitis A and potential Hepatitis A infection. Would ask more questions about any recent symptoms to suggest hepatitis A like nausea, vomiting, diarrhea and/or jaundice. I would check liver function tests. I would check serum Hepatitis A IgG and IgM to determine if acute infection or previous infection or immunization.

3. History of stroke: Continue atorvastatin. Check to see if the patient needs to be on an aspirin. Monitor blood pressure and treat if high. Advise the patient of the signs of stroke to watch for.

4. Childhood history of asthma. The patient still uses albuterol intermittently so watch for signs of asthma or reactive airway disease during hospitalization.

5. Pre-diabetes: Monitor blood sugars during hospitalization. Treat if elevated.

6. Chronic pain: Explore reason for use of gabapentin since 2016. Decide if this medication should be continued during this hospitalization or not.

7. Restless leg syndrome. Find out severity of symptoms and if she needs treatment during this hospitalization. No medications on med list to treat this symptom unless she is using the gabapentin to treat this.

8. Hearing loss: Ensure patient has hearing aids at bedside to aid in communication. Plans for cochlear implant in the future as an outpatient.