An 82-year-old man is seen for annual physical examination in the nursing home. He has resided there for 1 year because of the aggregate impact of multiple medical problems including, most prominently, laryngeal swallowing dysfunction associated with vocal cord paralysis. Among many interventions, has had laryngoplasty, arytenoid reduction, and Teflon injection of the vocal cords; despite these, he continues to have recurrent aspiration pneumonia. A percutaneous endoscopically placed gastrostomy (PEG) was performed; subsequently, orders stipulated nutrition and fluid exclusively through PEG tube, but he is often found noncompliant: eating popcorn.
Pleasantly interactive man whose voice is very soft owing to his vocal cord paralysis. PEG site not inflamed. Chest shows good air exchange, and no crackles, rhonchi, or wheezes. Penis as shown.
"WHAT'S YOUR DIAGNOSIS?"
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