Neurology Clerkships
Case 7  
Author: B. Jane Distad, MD
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This is a 57 year-old male with progressive weakness that began one year ago. At that time, he developed weakness of the left hand and arm. During an examination 9 months ago, he was identified to have weakness of left toe extension. Over the last 9 months he has noticed gradual worsening in all four extremities. The left side is weaker. Nothing seems to make it better nor is there a change with time of day. He denies diplopia, droopy eyelids, change in voice, swallowing difficulties, numbness, tingling, bowel or bladder dysfunction. He has lost weight from 172 lb to 160 lb over the past two months.

1. Chronic low back pain

1. Creatine

Allergies: NKDA

Family History: A sister has static weakness of unknown etiology noticed as an adolescent. Portuguese and Mexican descent.

Social History: No smoking

BP 128/72   HR 72   T 37.4°C
General: Well appearing.
Mental Status: Alert and O x 3
HEENT: CN II: Pupils equal, round, and reactive to light. III, IV, VI: 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. IX, X: Palate elevation is symmetrical in the midline. XI: Sternocleidomastoid was strong bilaterally. XII: No fasciculations or atrophy noted in the tongue. Normal bulk, strength and movement.
Motor (Power/Tone/Bulk): There is atrophy of the left foot and bilateral hand muscles. Fasciculations are prominent throughout all of the extremities. No contractures were noted. Normal tone. Distal upper and lower extremity weakness, extensors and flexors equally. Left 3/5 greater than right 4/5.
Sensory: Normal vibration, pinprick sensation.
Reflexes: 2+ upper extremities, 3+ lower extremities. Toes downgoing.
Coordination: Reduced bilateral finger tapping and left foot tapping. Normal finger to nose.
Gait: Bilateral foot drop.
Abnormal Movements: None.
Other Organs: None.

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