A Veteran With Lesions, Alcohol Use, and Opioid Dependence

R. Hal Scofield, MD


October 27, 2021

Physical Examination and Workup

Physical examination shows a thin man in no distress. He is oriented to self, time, place, and situation. His blood pressure is 134/82 mm Hg, his pulse is 92 beats/min, his respiration rate is 16 breaths/min, and his hemoglobin percent saturation is 94.

The results of chest percussion are normal, and the lungs are clear to auscultation. The heart rhythm is regular, with a normal rate. No murmur is detected. Bowel sounds are normal, and no abdominal tenderness is noted on palpation. Examination of the extremities reveals no edema or cyanosis. Multiple large ecchymoses are observed on all four extremities as well as on his trunk. In addition, multiple small ecchymoses are noted on the forearms; many of them are at the base of hair follicles. Similar skin lesions are shown below in a different patient (Figure 1).

Figure 1.

The neurologic examination shows that the pupils are round, equal, and reactive to light. Extraocular movements are abnormal. With far lateral gaze, the contralateral eye does not move beyond the midline. This finding is present bilaterally. Figure 2 shows similar ocular findings in a different patient.

Figure 2.

The patient has a wide-based, unsteady gait. He receives 28 of 30 points on a Mini-Mental State Examination.

A complete blood cell count reveals mild anemia, with a mean corpuscular volume of 102 fL (reference range, 80-95 fL). The platelet count is normal. The prothrombin time, partial thromboplastin time, and international normalized ratio are all normal. Levels of serum electrolytes, creatinine, and blood urea nitrogen are normal. The result of a random serum glucose test is normal. Serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels are both elevated, with an AST/ALT ratio of 2.1:1. The bilirubin level is elevated at 2.2 mg/dL (reference range, 0.1-1.2 mg/dL). Serum lactate and ammonia levels are normal.

A CT scan of the head shows neither acute bleeding nor a midline shift. Generalized atrophy is present.


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