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
BP (HR) supine 178/80 (68), standing
T 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
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
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.