Neurology Clerkships
Case 9  
Author: B. Jane Distad, MD
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A 57-year-old right-hand-dominant female complains of mild progressive weakness in the legs, and trouble climbing stairs over the past few months. Her symptoms may be slightly worse in the morning. More recently she has difficulty styling her hair. She denies double vision, sensory loss. She has mild myalgias. She has mild difficulties with swallowing solid foods and has stopped eating steak.


Albuterol inhaler

Family History: Negative.

Social History: Rare alcohol use, quit smoking 5 years ago after a 25 pack-year history, homemaker, married.

Review of Systems: Dry eyes and mouth, weight loss.

BP 128/88   HR 72    T 37.2°C
General: Thin. Mild distress.
Mental Status: Alert and oriented x 3. Speech without dysarthria, fluent.
HEENT: Neck supple. Full neck extension and flexion strength.
CN: Pupils were round with sluggish reactivity to light. The right pupil was 0.5 mm larger than the left. Extraocular movements were intact without nystagmus. Facial sensation was intact. Normal jaw strength. Normal facial strength. The palate elevated symmetrically in the midline. Normal sternocleidomastoid strength. The tongue was midline with full strength.
: Strength bilaterally: 4/5 biceps, deltoids, triceps; 5/5 wrist flexors, wrist extensors, interossei; 4/5 hip flexors; 5/5 hip extensors knee extensors and knee flexors, ankle dorsiflexors and plantar flexors. Biceps strength improved after 10 seconds of voluntary contraction. Difficulty standing from seated position without assistance. No fasciculations, scapular winging or atrophy. Normal tone.
Sensory: Sensation was intact to light touch, pin prick, vibration and proprioception bilaterally in the upper and lower extremities. Romberg was negative.
Reflexes: Absent at the biceps, triceps, brachioradialis, patellae and Achilles, with increase in the biceps and knee reflexes to 2+ following 10 seconds of activation of the muscle. Toes were down going to plantar stimulation bilaterally.
Coordination: Finger-to-nose and rapid alternating movements were intact bilaterally.
Gait: Slow, straight-away.
Abnormal Movements: None.
Other Organs: Noncontributory.

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