History and Physical — Patient 6

History

Patient #6 is a 69 year old white male who presented to the Department of Neurology for evaluation of possible muscular dystrophy. He first developed joint stiffness twenty years ago and was diagnosed with gout. About ten years ago, he developed weakness in climbing stairs and eventually in going down stairs. His weakness progressed slowly. He required a cane to ambulate and eventually a walker. By the time of admission, he would rarely walk because of a fear of falling. Within the past year, he developed difficulty in holding objects, as well as in reaching for objects. He denied any sensory symptoms. Specifically he denied numbness, tingling, pain, or loss of sensation. His weakness was not accompanied by any loss of balance, exaggerated difficulty in the dark, or tremors. He denied any stiffness, and claimed that his weakness was not aggravated by cold.

Patient #6's legs.

Patient #6's legs.

Review of systems was significant for dysphagia for solid foods and constipation and a past history of hypertension, gout, and left knee surgery. His only medication was atenolol for his hypertension. He was a previous smoker, but stopped fifteen years ago. He reported heavy drinking in the past, but stopped in his thirties.

The patient has no children; however he does have three brothers. All are in good health. There is no family history of muscular dystrophy.

Physical Exam

His vital signs were stable. His general physical exam was normal except for cataracts, frontal balding, and obvious generalized muscle wasting.

Neurological Examination

Mental Status: The patient was awake, alert, and oriented. He was cooperative and able to give a good history. His speech was fluent with intact repetition and comprehension.

Cranial Nerves: Normal with the exception of mild symmetric facial weakness.

Motor:

Neck flexion 4/5, neck extension 5/5.

Strength

Right

Left

Upper Extremities

  
Deltoid5-5-
Biceps43
Triceps33
Wrist Extensors55
Wrist Flexors55
Finger Extensors53
Finger Flexors33

Lower Extremities

  
Iliopsoas4-4-
Knee Extensors3+2+
Knee Flexors3+3+
Ankle Extensors3+3+
Ankle Flexors4+4+

 

Bilateral winging of the scapula was present. There was no evidence of percussion myotonia or action myotonia.

Reflexes: Biceps were 2/4 bilaterally. Remaining reflexes were 1/4. The jaw jerk was not hyperactive and Hoffman and Babinski signs were not present.

Sensation: Decreased to pinprick in a stocking distribution bilaterally. Touch sensation was intact in upper and lower extremities. Proprioception and vibration sense were also intact.

Cerebellar: Finger-to-nose was normal, as well as finger tapping. Heel-to-shin showed some difficulty, felt to be due to weakness. There was no truncal ataxia.

Gait: Difficulty in arising from a chair. He was cautious, but steady. He had difficulty lifting his legs off the ground, and could not walk on his toes or his heels.

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