Neurology Clerkships
Case 13b  
Author: B. Jane Distad, MD
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This is a 79 year-old male who became slower in his mobility, developed hoarseness, severe dysarthria, some cognitive decline, and worsening of his gait over the past year. He has had a number of evaluations for possibility of stroke, and for lower extremity radiculopathy in the setting of lumbar spinal stenosis. He has had neuropsychological testing suggesting cognitive deficits. He started Sinemet, with questionable improvement in overall mobility, but perhaps his facial expression is improved.

1. Intermittent atrial fibrillation
2. Lumbar spinal stenosis with chronic right foot drop and sensory loss in both feet.

1. Sinemet 25/100 tid
2. Tylenol prn

Allergies: PCN - hives

Family History: Negative for neurological disorders.

Social History: Retired engineer, frequent trips to China.

BP (HR) supine 178/80 (68), standing 184/94 (72)   
36.50°C    Wt 194 lb
General: Mildly disheveled.
Mental Status: Speech severely dysarthric and hypophonic. Significant difficulty with following a four-step command. He was slow to respond to most questions. Word-finding difficulty for more difficult words, although he had no trouble with easy words.
HEENT: Visual fields are intact and his pupils react symmetrically. His extraocular movements are markedly abnormal in that smooth pursuit is broken down; saccadic eye movements are extremely slow with slow initiation. He has limited upgaze and downgaze. He has reduced facial animation but intact facial sensation. Slow tongue movements with a question of tongue fasciculations with the tongue resting on the floor of the mouth.
Motor (Power/Tone/Bulk)
: Neck tone is markedly increased. There is mild rigidity in the arms and a bit more in the lower extremities; Mildly weak in the right lower extremity with foot dorsiflexion and toe extension. He needs to push himself off the chair.
Sensory: Abnormal bilaterally in the distal lower extremities, the vibratory sense is completely absent at the toes. He has patchy numbness over the dorsum of the right foot. Joint position sense is normal in the toes.
Reflexes: Tendon reflexes are 2/4 in the upper extremities, 3/4 at the knees, but 0/4 at the ankles bilaterally. Plantar responses are flexor on either side.
Coordination: Moderate to severe, symmetric bradykinesia with rapid alternating movements, finger-tapping and foot-tapping. FNF is accurate.
Gait: He is quite unsteady on his feet and requires assistance for safe ambulation and uses a walker.
Abnormal Movements: No tremor or involuntary movements.
Other Organs: He has moderate lower extremity pitting edema halfway up the shin.

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