Neurology Clerkships
Case 13a  
Author: B. Jane Distad, MD
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This is a 61 year-old, right-handed female with symptoms that began over the past one to two years. Onset was fairly sudden with change in her speech characterized as slurred and softer. Shortly thereafter she noticed a tremor of her hands that is most prominent at rest, and difficulty moving her legs. The left foot also slaps when she is walking and feels like it is shorter. She previously walked five miles per day, as recently as six months ago, but now has difficulty even walking around the block. Her left hand is slower and occasionally has difficulty initiating movements with this arm. She has no difficulty turning over in bed, or controlling secretions. She denies shortness of breath.

Review of Systems: Positive for overall weakness, balance difficulty, leg pain with walking, left ankle swelling, chronic low back pain.

1. History of deep venous thrombosis and pulmonary embolus
2. Status post Greenfield filter
3. Dyslipidemia

1. Prempro
2. Coumadin
3. Simvastatin

Allergies: NKDA

Family History: Negative for neurologic disease, tremor.

Social History: She does not smoke or use alcohol.

BP 158/62   HR 96    T 37.00°C   Wt 184lb
General: Well appearing.
Mental Status: Alert. Orientation was normal to time, place and person. Speech was rapid, hypophonic, tapering off at the end of sentences. Serial sevens and recall of three items at 5 minutes were intact.
HEENT: Mild neck rigidity. II: Visual acuity to hand-held card: OD 20/25 and OS 20/30. Visual fields were full to confrontation. Funduscopic examination revealed flat discs with venous pulsations seen bilaterally. III, IV, VI: The pupils were equal, round and reactive to light and accommodation. Extraocular movements were full, without nystagmus. V: Normal facial sensation. VII: There was a symmetrical nasolabial fold without volitional weakness. VIII: Hearing was intact to finger rubbing bilaterally. There was mild masked facies. IX, X: Palate elevation was symmetrical in the midline. XI: Sternocleidomastoid was strong bilaterally. XII: Tongue with normal bulk, strength and movement.
Motor (Power/Tone/Bulk)
: There was mild right upward drift. Tone was mildly increased on the left and augments with distracting maneuvers bilaterally in the upper extremities. Strength: Upper and lower extremities 5/5.
Sensory: Normal to light touch, pinprick, vibratory sense and joint position sense. Romberg test was negative.
Reflexes: 2+ biceps, triceps, brachioradialis, knees, and 1+ ankles. Glabellar absent. Snout present. Toes downgoing.
Coordination: There was subtle micrographia. Archimedes circle drawing demonstrated very fine tremor. Finger-to-nose testing was without dysmetria, but there was tremor present bilaterally. Fine-finger movements and rapid alternating movements were of lower amplitude and mildly slowed.
Gait: Her left arm swing was absent and the right mildly reduced. Gait was mildly wide-based without evidence of shuffling and no stoop. There was mild retropulsion.
Abnormal Movements: Tremor was present at rest in the hands. There was a rapid low frequency rest tremor of the jaw, the muscles around the eyes.
Other Organs: 2+ pitting edema of the left lower extremity to the knee.

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