History and Physical — Patient 33


Present Illness: Patient #33 is a 32 year old right-handed Filipino man who presented for evaluation of tremors. His symptoms started five years ago when he noticed that his hands would shake when he reached for a cup or shaved. He also noticed that he would drag his right leg with occasional tripping. These symptoms slowly worsened to the point that the tremor persisted during rest, causing him to leave his job as an ICU nurse. He also noticed balance problems, although he has not fallen. However, when his young son pushes him, he staggers backwards and nearly falls. His wife also thinks that he is "walking like a robot". Recently, he noticed involuntary movements of his mouth. His hands tend to cramp if he makes a fist, and this worsens as the day progresses. However, he has not experienced writer's cramp. Stress and fatigue worsen all of these symptoms. He denies bruxism, change in speech, visual changes, weakness, or numbness.

Past Medical History: None.

Developmental History: Normal.

Allergies: No known drug allergies.

Medications: None.

Family History: Maternal grandfather had "Parkinson's disease"; no other history of neurologic disease.

Social History: Denies any history of alcohol or tobacco use. Denies any history of neuroleptic use, illicit drugs, or any antidopaminergic agents.

Physical Exam

General: Pleasant man appearing of stated age, in no apparent distress.

Vital Signs: B.P. 164/83; pulse 68; temperature 98.0 F; respiration 20.

HEENT: Normocephalic, atraumatic. Oropharynx clear.

Neck: Supple without JVD, thyromegaly, bruits, or lymphadenopathy.

Chest: Clear to auscultation bilaterally.

Cardiovascular: Regular rate and rhythm without rubs, gallops, or murmurs.

Abdomen: Soft; normal bowel sounds. No organomegaly or tenderness.

Skin: No rashes or lesions.

Neurological Examination

Mental Status: 30/30

Speech: Normal fluency, comprehension, and repetition. He has no difficulty with labial or lingual speech, but has mild guttural dysarthria.

Cranial Nerves:

Cranial Nerves


INot tested.
IIPupils equal, round, and reactive to light. Visual fields full to confrontation. Fundoscopic exam normal.
III / IV / VIExtraocular movements intact.
VNormal sensation in all three distributions of the trigeminal nerve. Normal strength of temporalis and masseter muscles.
VIINormal facial strength bilaterally.
VIIIHearing intact to bilateral finger rub. Normal Rinne and Weber test.
IX / XGag reflex normal.
XISternocleidomastoid 5/5 bilaterally.
XIITongue protrudes in midline without atrophy or fibrillations.


Motor: Strength 5/5 throughout. Oromandibular jaw-opening dystonia is present, as is occasional dystonia of both feet. 2+ 8-9 Hz tremor is present when the arms are outstretched, with a 2+ kinetic tremor as well. 1+ bradykinesia and cogwheeling are present in all four extremities. No myotonia or myoclonus is present.

Reflexes: 3+ and symmetrical in bilateral biceps, triceps, brachioradialis, patellas, and ankles. Plantar responses are flexor; no Hoffman's sign. A glabellar sign is present.

Sensation: Normal to pinprick, light touch, vibration, temperature, proprioception, stereognosis, and graphesthesia.

Cerebellar: No dysmetria, but limited due to tremor. Difficulty with rapid alternating movements in the left upper extremity.

Gait: Slightly wide-based with poor arm swing. Holds hands in fists while walking. No stooped posture, but he has significant retropulsion and loss of postural reflexes. Able to tandem walk, but trips easily due to foot dystonia. Mild circumduction of right leg.

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