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
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
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.
Coordination: Reduced bilateral finger tapping and left
foot tapping. Normal finger to nose.
Gait: Bilateral foot drop.
Abnormal Movements: None.
Other Organs: None.