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CPC

CPC. Kenn Ghaffarian PGY3 October 12, 2014. 38 M p/w altered gait. HPI. Altered gait 2 months, worsening over past few days F alls to the left when walking Worse going upstairs, unchanged when eyes are closed Denies any weakness of the extremities +numbness of toes bilateral feet

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CPC

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  1. CPC Kenn Ghaffarian PGY3 October 12, 2014

  2. 38 M p/w altered gait

  3. HPI • Altered gait 2 months, worsening over past few days • Falls to the left when walking • Worse going upstairs, unchanged when eyes are closed • Denies any weakness of the extremities • +numbness of toes bilateral feet • + intermittent confusion, trouble carrying on conversation • 2 weeks of R sided throbbing HA, worse at night and when supine, 8/10 • Reports presyncopal sensation few times per week, worse at night, with no associated symptoms.

  4. ROS • +subjective fevers for 2 weeks • +fatigue, + weight loss • +blurred vision when looking to L, not currently present • CP- R sided, constant and sharp, no SOB • Denies cough • Denies abd pain, no vomiting, no diarrhea • No dysuria • No back pain • +depression

  5. PMHx • HIV+ for 8-9yrs, never on HAART until approx 3 weeks ago • CD4 count at that time = 5 • On Bactrim • DM, not on PO or insulin • Asthma • Quit tobacco/ETOH 1 month ago, denies illicit Rx use

  6. Vitals • 37.5 • HR 103 • BP 136/69 • RR 16 • 100% RA

  7. Physical exam • Alert and oriented x 4, NAD • Skin: Warm, dry, no rash • Head: NC/AT • Neck: supple, no ttp • Eye: PERRL, EOMI, bilateral horizontal nystagmus • ENT: clear TMs, MMM • CV: RRR, no murmur • Lungs: CTAB • Chest Wall: no TTP, no deformity • GI: Abd soft/NT/ND

  8. Neuro Exam • A & O x 4 • CN 2-12 intact • Normal sensory • Normal motor • Normal speech • Normal coordination including finger-nose, heel-shin • + Romberg's, wide based ataxic gait falling to R • Symmetric reflexes bilaterally, down-going plantar reflex

  9. Labs • WBC 4.7 • (19.2% lymphs) • Hgb 12.7 • Hct 36.4 • Platelet 443 • NH4- 20.8 • Lipase 91 • Na 133 • K 4.6 • Cl 99 • CO2 23 • BUN 9 • Cr 1.0 • Anion Gap 11

  10. Labs • LFT’s • Alk Phos 66 • Tbili 0.9 • Dbili 0.4 • Alb 4.1 • Globulin 3.7 • Tprotein 7.8 • ALT 17 • AST 16 • UA • Clear, Yellow • Neg glucose • Neg bili • Neg ketones • Specific gravity 1.011 • Neg blood • Neg protein • Neg nitrate • Neg leuk est • Wbc <1 /hpf • RBC <1 /hpf

  11. EKG

  12. CXR

  13. CTH

  14. CTH w IV contrast

  15. Lumbar Puncture • Opening pressure 17 cm H2O • Clear, colorless CSF • WBC 5 • Segs 0%, • Lymph88% • Mono 12% • RBC 6 • Glucose 44 • Protein 55

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