The Neuro Exam Yields

by chelseajin

I got all excited to start peppering in extra stuff in my physical exam, but then I saw the new resident drive in and I was like “awwww….”.

But it was great to catch this one new woman who came in.

Betty had seen her just once before and she wasn’t looking well then either. I translated between the two and found that she had been feeling constantly fatigued for a long time. She didn’t have any shortness of breath or chest pain.

She fit the typical older Mexican woman body structure, short stature and round face and limbs. Betty pointed out that her hair was thinning a little, and indeed, it did look sparse.

The patient was understandably worried because she said she had to be hospitalized in Mexico for 3 days for symptoms of overwhelming fatigue, aches, and leg pains. Apparently the doctors there had told her she had Lyme disease. But she didn’t recall having a target-shaped bite anywhere.

It sounded strange to us that she could get Lyme disease in the area (Mexico and Arizona), but the U of A has some information posted saying that the black-legged (Ixodes Pacificus) tick is the vector here, where they can survive, in the mountains just at about this time in the late winter and early spring.

I caught her saying something about sweating while speaking to the resident, and I asked her more about that, and she confirmed that she had night sweats. Did she feel abnormally hot or cold? Yes. She had also lost a lot of weight recently. She also had a constant back/flank pain. But no difficulty/pain upon urination.

I don’t know about Lyme disease, maybe she had it, but it didn’t sound like that’s what was bothering her now. She didn’t really have that characteristic joint pain, and the other symptoms she had were broadening the differential. I was thinking maybe Tuberculosis,  Coccidiodes (finally!! I mean, we’re in Arizona!!), or hyper/hypothyroidism.

I think Betty could tell that I was all raring to do the neuro exam. She had CN 7 facial nerve nerve weakness which I could see from a poor effort in puffing out her cheeks and grimacing. In fact, I even poked them lightly and they collapsed.

She had muscle weakness all around, and afterwards, she told me that she was just spent from pushing against the resistance I was providing for the exam.

Betty did a breast exam and felt the thyroid after that, but it didn’t turn up anything. One Easter egg was checking her abdomen. She hadn’t made any kind of complaint before but upon deep palpation, her face turned red and it was clear that it was extremely unpleasant, or as we like to say “exquisitely tender”.

Who knows if this is part of the fatigue. She had a large scar descending from her belly button, and told me she had an appendectomy because it had burst, which later progressed to peritonitis. She recalled about 4 surgeries total, all close to each other in time, so adhesions could also be the cause of pain.

Once again, reverse mentality takes place in that that was fun to work up…although being sick is not fun.

I had a strange moment afterwards once I was home and doing the laundry.

This elderly gentleman starts talking to me.

Just imagine a background of rumbling washers and driers.

Just imagine a background of rumbling washers and driers.

I went through almost the entire conversation thinking he had mistaken me for someone else. I was really on my way out and had a bag of clean clothes under my arm, just sort of hanging off the doorknob, one foot outside already when he starts telling me that he was a pretty fit guy but then got prostate cancer and it ended a lot of things for him. It’s strange watching traumas leak out of people. I’ve noticed that lonley/depressed people tend to be talkative with strangers. Not that he is any of that, but that’s what it makes me think about.

He invites me to a gunshow in Old Tucson where he’ll be a judge. He told me he from LA and had been a stuntman for over 15 years. You can tell he’s an old guy, but I don’t think anyone would guess that he was 80. He had a really firm handshake, not something I run into that often.