History and Physical — Patient 25

History

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.

Physical Exam

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.

Neurological Examination

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.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIVisual acuity 20/20 OU; visual fields full to confrontation; pupils 3 mm and reactive to light and accomodation; fundoscopic exam WNL.
III / IV / VIExtraocular movements full without nystagmus or ptosis; no ocular dysmetria.
VIntact sensation in all three divisions bilaterally; intact masseter and temporalis strength.
VIISmile symmetrical.
VIIIHearing intact to finger rub bilaterally; Weber non-lateralizing; air>bone conduction.
IX / XPalate elevates in midline; gag intact bilaterally.
XIISCM 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.

Strength

Right

Left

Upper Extremities

  
Deltoid55
Biceps55
Triceps55
Wrist Extensors55
Wrist Flexors55
Finger Extensors4+4+
Finger Flexors4+4+
Hand Intrinsics4+4+

Lower Extremities

  
Iliopsoas4+4+
Knee Extensors55
Knee Flexors55
Ankle Extensors5-5-
Ankle Flexors55

 

Reflexes: Babinski's were present bilaterally. There was no Hoffman's sign. Palmomental and snout signs were present.

Reflex

Right

Left

Biceps11
Triceps11
Brachioradialis 11
Patellar
Ankle

 

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.

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