Neurology Clerkships
Case 20  
Author: Eric Kraus, MD
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This is a 39 year-old male with numbness in the arms and legs. Starting six to eight weeks ago, he noticed symmetric numbness on the soles of both feet. About three days later, he noticed numbness in the palms of both hands in all five fingers. It has progressed in the legs, first to the calves where it stabilized for three weeks, then progressed to the knees, and finally to the hips. He has had some saddle anesthesia for the last two to three weeks. Recently, somebody grabbed him around the midsection and felt his ribs were different. Occasionally, he has some tingling in his forearms. He does not report specific weakness in his arms or legs, although he has been dropping pills and had a fall three weeks ago. He feels unsteady on his feet, and particularly the left leg and foot are ataxic. He has fatigue, but also poorly-treated depression.

Review of systems positive for dizziness, some pain in the legs, tremor, anxiety, depression, change in sweating, leg pain, shortness of breath, intolerance to heat, and weight gain. The patient denies trouble with speech, swallow, bowel, bladder, vision, or cognition. He has never had a similar symptom that has come and gone in the past, including vision, motor, or sensory function.

1. HTN
2. Depression
3. Anxiety
4. Left eye strabismus and amblyopia

1. Altace 15mg qd
2. Clonazepam 0.5mg qd

Allergies: None

Family History: Noncontributory

Social History: Unemployed. Single. Smokes. Drinks 1/week.

BP 116/70   HR  96   T 36.80°C
General: Disheveled.
Mental Status: Alert. Orientation, memory, and language all seem normal.
HEENT: Left exotropia is quite significant on the cover/uncover test. Right eye is dominant. Visual acuity and funduscopic exam not done. Face normal to motor and sensory exam. Oropharynx benign with tongue and palate midline. Good tongue strength. No fasciculations.
Motor (Power/Tone/Bulk)
: 5/5 in all muscle groups with ability to walk on toes and heels, and get from a low chair to a standing position without using his hands. Tone is okay in the legs.
Sensory: Vibration is decreased at the right ankle and absent even at the left knee. Proprioception is grossly okay in the toes. Light touch is decreased in legs and hands. Pinprick seems normal. Romberg positive.
Reflexes: 1/4 at right triceps and 1+/4 at left, 0/4 at right biceps and 3/4 at left, 0/4 at right wrist and 2/4 at left, 3/4 at knees, 1/4 at right ankle and 0/4 at left. Toes equivocal. Abdominal reflexes are markedly positive in all four quadrants.
Coordination: Heel-to-shin maneuver shows mild bilateral dysmetria.
Gait: Heel-to-toe walking is very clumsy but walking is normal otherwise.
Abnormal Movements: None
Other Organs: Carotid auscultation is negative.

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