History and Physical — Patient 22

History

The patient is a 60 year old right-handed Asian male presenting with a six year history of gait and balance difficulty.

The patient notes progressive difficult initiating gait, frequent tripping, and difficulty gauging the height of stairs. Over the past six years, he has fallen repeatedly. He has difficulty arising from chairs, frequently falling back into the chair when attempting to rise. Others have noted a stooped posture, decreased facial expression, and generalized slowness of movement.

Recently, he has developed slurred speech with a progressive difficulty in expression. He also complains of difficulty using his hands with simple tasks. In particular, his writing is now illegible. He also complains of orthostatic dizziness, chronic constipation, urinary retention with overflow incontinence, occasional fecal incontinence, and erectile dysfunction. He denies dysphagia, diplopia, and dizziness.

Physical Exam

General: The patient is a well-developed, well-nourished Asian man, appearing his stated age.

Vital Signs: B.P. 160/100 supine; 117/73 standing; pulse 84; temperature 97.6 F; respirations 18.

HEENT: Normocephalic, atraumatic; sclerae are anicteric; conjunctivae are pink; oropharynx is clear and moist without lesions; neck is supple without lymphadenopathy or bruits.

Chest: Lungs are clear to auscultation and percussion bilaterally; excursion is WNL.

Cardiovascular: Heart shows a regular rate and rhythm without rubs, gallops, or murmurs; PMI is not displaced; peripheral pulses are normal.

Abdomen: Soft, nontender without hepatosplenomegaly; there are no bruits.

Extremities: No cyanosis, clubbing, or edema.

Skin: No abnormal hypo- or hyperpigmented skin lesions. No rash.

Neurological Examination

Mental Status:

Area

Findings

Behavioral ObservationsThe patient answers questions and processes information slowly.
AffectBlunted.
AttentionIntact.
LanguageIntact comprehension, repetition, naming, reading, and writing. Fluency is decreased to 11 words per minute. Speech is dysarthric with impaired labial and lingual sounds.
MemoryImpaired short-term memory with difficulty in recalling 2/3 words at 5 min. The patient was able to recall both words with cues.
Constructional AbilityIntact.
Abstract ThinkingIntact.
CalculationsMildly impaired calculation ability.
PraxisIntact.

 

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils equal, round, reactive to light and accomodation; visual acuity 20/20 OU; visual fields intact to confrontational testing.
III / IV / VIExtraocular movements intact to command, and following finger; visual scanning normal; OKN responses normal; no nystagmus or impaired voluntary gaze.
VSensation to light touch and pinprick in all three divisions bilaterally; corneal responses intact bilaterally; muscles of mastication show normal strength.
VIISmile is symmetrical.
VIIIIntact to bilateral finger rub.
IX / XPalate and uvula rise symmetrically; gag is intact bilaterally.
XISternocleidomastoid and trapezius strength intact bilaterally.
XIITongue is midline without atrophy or fibrillations.

 

Motor: Tone was slightly increased on the left side. Muscle bulk was normal throughout without atrophy or fasciculations. There was no cogwheel rigidity and no tremor was present. Bilateral strength testing of both the upper and lower extremities was 5.

Reflexes: Bilateral 3+ for upper and lower extremities. Spread was present in the biceps, triceps, and brachioradialis bilaterally. There was no Hoffman's sign present. Babinski signs were present bilaterally. Jaw jerk was positive.

Sensation: Intact to pinprick, light touch, vibration, and temperature sense throughout. There was a mild decrease in proprioception in the left toes.

Cerebellar: Finger-nose-finger testing showed dysmetria bilaterally, right > left; heel-shin testing showed dysmetria bilaterally; rapid alternating movements were impaired in the right upper extremity; there was loss of check in the bilateral upper extremities; mild ocular dysmetria was present.

Gait: Stance was wide-based and unsteady; gait was wide-based with decreased arm swing on the right side. The patient turned en bloc. There was marked retropulsion. The patient was unable to tandem walk, but could walk on heels and toes with assistance. When supine, leg movements were as badly affected as when the patient stood.

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