4. General History by Dr. Shambaugh, August 2, 1932.
GENERAL HISTORY AND EXAMINATION
Aug. 2, 1932.
COMPLAINT Pains in the head for three months.
- F. 73, l. & w.
- M. 72. l. & w.
- 11 siblings - 6 l. & w: 2 l. but have tuberculosis; 1 S. d. of tuberculosis; 1 B. d. of unknown cause, and 1 B. d. in infancy. No history of cancer, diabetes, heart trouble or kidney disease.
- Married 22 yrs. Husband is living at 52, but has suffered from ulcers of the stomach for 30 yrs. 2 children l. & w. 1 d. of diphtheria at 3½. No miscarriages.
- Born in Nova Scotia and has lived in this vicinity for ten years. She had scarlet fever in childhood, and diphtheria ten years ago, at the time of her baby's illness. Fifteen years ago at the age of 27, she had pulmonary tuberculosis, and spent 6 months in a sanitorium in Nova Scotia. Her ill ness was characterized by marked weight loss, - she went down to 98 lbs. for 125 lbs. - a chronic hacking cough, occasionally blood-streaked sputum. No pleurisy or gross hemoptysis. She was discharged from the sanitorium as an arrested case. And aside from occasional mild cough she has had no symptoms since. X-rays of the chest have been taken occasionally since that time. The last plates were taken 3 years ago at the M.G.H., and were reported negative except for old scars. No malaria, typhoid fever, pneumonia, small pox, rheumatic fever or chorea.
- Injuries - 0.
- Operations - Tonsillectomy twice. The first time 19 years ago, the 2nd time seven years ago.
- Appendectomy (sic) 22 years ago in Nova Scotia under ether anaesthesia.
- Uterine suspension in Nova Scotia 14 yrs. ago under ether anaesthesia.
- Hysterectomy and bilateral salpingectomy 8 yrs. ago for fibroids at the M.G.H. under ether.
- Occasional headaches all her life, usually with her periods. No vertigo.
- Glasses worn for 20 years. See P.I.
- Otitis media on the left 8 yrs. ago. No deafness or residual discharge.
- No chronic coryza or recurrent epistaxis.
- All teeth out. The uppers removed 25 yrs. ago and the lowers 3 yrs. ago for general caries. Frequent sore throats all her life. There was recurrent attacks of tonsillitis and two peri-tonsillar abscesses, the last one seven years ago on the left. No sore throats or tonsillitis since tonsillectomy 7 yrs. ago. No sore tongue or dysphagia.
- No dyspnoea, swelling of the ankles, orthopnoea, palpitation or chest pains. See above for history of tuberculosis.
- Appetite good. Bowels regular with only occasional cathartics. No nausea, vomiting, distress, belching of gas or sour eructations. No abnormal stools noted. No hemorrhoids.
- No dysuria, hematuria, frequency. Nocturia 1-2 a night for 5-6 yrs. Denies venereal disease by name and symptoms.
- Began at 15, regular every 28 days, always associated with considerable pain. 8 yrs. ago she had considerable menorrhagia, resulting in a diagnosis of fibroids with the removal of all pelvic organs. She has had no periods since, and still has hot flashes.
- Tea - 5-6 cups; no coffee, alcohol, tobacco or drugs.
- 130 lbs. No recent loss.
- For the past 3-4 years she has had occasional mild headaches, mainly in the back of the head and extending up to the top, lasting 10-12 hours, and occurring every one or two months. Three months ago these headaches became considerably more severe and more frequent, and since that time have become almost constant, often awakening her at night, and preventing sleep. They have been only slightly relieved by aspirin.
- For about the past three months she has noticed that her right arm tires quite easily and there has been some weakness of the right hand. For about two months she has noted some weakness in the legs also, particularly the right, and she has noticed that while walking in the street she finds herself veering toward the right. Recently she has occasionally bumped into people, but has never fallen. There has been a general lassitude and tired feeling during the past several months, and at the same time she sleeps but very poorly.
- During the past month she has noticed a rapidly increasing dimness of vision with inability to read fine print for 3 weeks. She believes this visual defect has been more marked on the left. During the past month she has had occasional nausea with the severe pains in the head by no vomiting.
- Two months ago she consulted a local physician because of her general tired feeling, and she was told that her nerves were in bad condition and needed a thorough rest. She was given a tonic and sedatives, and was advised to take a vacation in the country. She had made all her plans to leave for Nova Scotia 4 weeks ago when she decided to consult an optometrist because of her dimness of vision, to see if her glasses needed changing. Her eyes were tested, and she was fitted with a new pair of glasses, and returned one week later with no relief. The optometrist again tested her vision and found it to be considerably decreased over the previous examination. He examined her eyes with ophthalmoscope and told her that her trouble was in the nerves back of her eyes. She was referred to an ophthalmologist, Dr. G.H. Ryder of Wollaston, who told her that her eyes showed signs of cerebral pressure on the nerve and gave her a letter to Dr. Taylor, the neurologist. Dr. Taylor being indisposed and unable to see the patient she was sent to this clinic for further advice and treatment. She was seen by Dr. Light in the O.D.D. 3 days ago, who advised her to come into the hospital.
- Reveals a w.d. and w.n. middle aged woman, lying comfortably flat in bed, breathing easily. She is well oriented, mentally quite acute, and cooperative, and gives a reliable history. Her general demeanor is run under extreme lassitude, however. There is an obvious slight right facial weakness, and a slight ptosis of the right eyelid.
- Symmetrical and well formed. No exostoses, scars, or tenderness. No bruit.
- Pupils are equal, regular and react promptly to l. & a. Extraoccular movements normal. No strabismus, exophthalmos or lid-lag. Ophthalmoscopic examination reveals clear media, discs show the superior and nasal margins completely obliterated, but there is no measurable elevation. There is slight bilateral temporal pallor. Fundi are normal in color. Veins appear somewhat tortuous. There is a small irregular fresh hemorrhage just above the discs in both eyes. No exudate seen.
- Negative for mastoid tenderness, tophi or discharge.
- No obstruction, discharge or bony deformity.
- Teeth all removed. Upper and lower dentures worn. Tongue is clean, protrudes in the midline with tremor. Tonsils not seen. Throat not injected.
- Thyroid barely palpable, but not enlarged, no shocks or thrills.
- Symmetrical and well formed. Expansion equal.
- Slightly atrophic with no scars, tenderness or masses.
- Resonant thruout to percussion. B.S. vesicular thruout. Tactile fremitus normal. No rales heard.
- Not enlarged to percussion. apex impulse not seen or felt. Action regular. Sounds of good quality with no murmurs or thrills.
- Equal, regular, synchronous, of good quality. V.W. easily compressed.
- Blood Pressure
- Systolic 115
- Diastolic 70
- Level, soft and tympanitic. Three scars in the lower abdomen, one in the r.l.q., and two in the midline - all well healed. No tenderness, masses, spasm or palpable organs.
- Equal in length and well formed. There is slight weakness of the right arm and leg. No demonstrable sensory changes.
- Biceps, triceps and radial periosteal reflexes are active and equal on the two sides. K.j. and Achilles reflexes are somewhat hypoactive but equal. No ankle clonus, Kernig or Babinski.
- Introitus marital. Cervix small, hard and in good position. Fundus not felt. Vaults clear.
- No hemorrhoids. No masses felt.
- A 43 year old housewife enters complaining of pain in the head for 3 months, general lassitude, slight weakness of the right arm and leg, and progressive dimness of vision. There is a family history of tuberculosis, and the patient herself had pulmonary tuberculosis 16 yrs. ago, but has had no symptoms of activity since. Her pelvic organs were removed at the M.G.H. 8 yrs. ago for fibroids of the uterus.
- P.E. reveals right facial palsy with ptosis on the right; slight weakness of the right arm and leg, and bilateral early choking.
- Cerebral neoplasm, left parietal.