History and Physical — Patient 25
Patient # 25 is a 32 year old right handed male who presented with a progressive gait disorder.
Three years ago, the patient first noticed difficulty walking in a straight line but did not think much of the problem. Over the next two years, however, this difficulty progressed to the point where he could no longer deny it. By this time, his gait was unsteady and "drunken", causing him to trip frequently especially when turning. He noted marked difficulty negotiating stairs, especially when walking down. At night, in the dark, his unsteadiness worsened. He was diagnosed with a peripheral neuropathy by another neurologist and sent to our center for further investigation and treatment.
The patient denied any muscle wasting, weakness, fasciculations, muscle stiffness, tingling, numbness, visual disturbance, dysarthria, dysphagia, diplopia, incontinence, or memory disturbance. He is able to walk up to three miles a day, but his legs fatigue easily.
Past Medical History: Unremarkable.
Past Surgical History: None.
Allergies: No known drug allergies.
Medications: Tylenol, as needed.
Family History: No neurological disorders; specifically, no gait abnormalities.
Social History: Unmarried tire salesman with no history of alcohol, tobacco, or drug abuse. He denied any HIV risk.
General: Well developed, well nourished male in no acute distress.
Vital Signs: B.P. 132/60; pulse 70; temperature 97.6F; respiration 18.
HEENT: Normocephalic, atraumatic; sclerae anicteric; conjunctivae pink; oropharynx clear, moist without lesions; neck supple without lymphadenopathy, thyromegaly, bruits.
Chest: Clear to auscultation and percussion bilaterally.
Cardiovascular: Regular rate and rhythm without rubs, gallops, or murmurs; PMI not displaced.
Abdomen: Soft, nontender, without visceromegaly.
Extremities: No cyanosis, clubbing, or edema.
Skin: No significant hyper- or hypo- pigmented lesions.
Mental Status: The patient was alert and fully oriented. MMSE was 30/30. Attention was intact, and speech was fluent without paraphasic errors. Comprehension, naming, repetition, reading, and writing were all intact. Short-term memory was intact, as well as constructional ability.
|II||Visual acuity 20/20 OU; visual fields full to confrontation; pupils 3 mm and reactive to light and accomodation; fundoscopic exam WNL.|
|III / IV / VI||Extraocular movements full without nystagmus or ptosis; no ocular dysmetria.|
|V||Intact sensation in all three divisions bilaterally; intact masseter and temporalis strength.|
|VIII||Hearing intact to finger rub bilaterally; Weber non-lateralizing; air>bone conduction.|
|IX / X||Palate elevates in midline; gag intact bilaterally.|
|XII||SCM and trapezius strength intact bilaterally.|
Motor: Tone was normal. Muscle bulk was normal. There was no cogwheel rigidity or tremor. Strength in the neck flexors and extensors was 5/5.
Reflexes: Babinski's were present bilaterally. There was no Hoffman's sign. Palmomental and snout signs were present.
Sensation: Decreased pinprick, temperature, and light touch in a symmetrical stocking distribution up to the mid thigh on the leg and a glove distribution up to the mid arm; absent vibration and proprioception in the toes bilaterally; decreased vibration and proprioception in all four limbs; Rhomberg was positive.
Cerebellar: Mild dysmetria on finger-nose-finger; moderate dysmetria on heel-shin test; slight truncal titubation; rebound test positive; mild dysdiadokokinesia in the fingers, more pronounced on toe tapping.
Gait: Unsteady, slow, wide-based, with irregular stride length; arm swing normal; the patient attempted to turn on a pivot but was very unsteady; able to walk on toes and heels in an unsteady manner; unable to tandem walk.