Neurology Clerkships
Case 37  
Author: Gregg Meekins, MD
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This is a 37 year old male with a four year history of progressive, lower extremity cramping pain and difficulty with ambulation. He notes decreased range of motion at the hip and knees secondary to “tightness” of leg muscles. There is increasing difficulty with turning or bending at the waist. He has also noted painful spasms in the thoracic region. There is no weakness in the extremities. There has been no disturbance of sensation. He remains continent of both bowel and bladder function.

Review of systems positive for exercise intolerance secondary to shortness of breath.

1. Insulin dependent diabetes mellitus (type 1) at age 27
2. Hashimoto’s thyroiditis at age 32

Medications (Outpatient):
1. Levothyroxine 0.1 mg po qd
2. Lispro Insulin 10 units subq q AM and 12 subq q PM
3. Glargine Insulin 18 units subq q AM and 12 units q PM

Allergies: NKDA

Family History: Father deceased age 70 from myocardial infarction. Mother diagnosed with Schizophrenia and Parkinson’s disease.

Social History: Works as a computer programmer. Married with no children. Denies alcohol, tobacco or recreational drug use.

BP 135/75   HR 65   T 36.8°C
General: Thin, hyperlordosis of lumbar spine noted on standing.
Mental Status: Alert, appropriately conversant.
HEENT: Normocephalic, Funduscopic exam normal, otoscopic exam normal, direct testing of cranial nerves II-XII is normal.
Motor (Power/Tone/Bulk): Increased tone in the arms, back and legs. Hypertrophy of leg muscles is noted. No tremor. Strength is graded 5/5 in upper and lower extremity muscle.
Sensory: No asymmetry to pin-prick or vibration in the extremities or trunk.
Reflexes: 3+ symmetric at the biceps, triceps, brachioradialis, patellar and Achilles tendons. Toes are downgoing to plantar stimulation.
Coordination: Normal on FTN testing.
Gait: Circumduction about the knees, en-bloc turns noted.
Abnormal Movements: None
OtherOrgans: Heart RRR with no murmurs. Lungs clear to auscultation. No organomegaly. Skin normal.

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