ASSESSMENT: This 38 year-old female has gradually progressive coordination difficulty that localizes best to the central nervous system. The ataxia, truncal titubation, and dysmetria suggest cerebellar dysfunction. Although her gait looks a little spastic, she does not have any features of spasticity on direct examination and toes are down. The proprioceptive loss could be posterior column or a mild peripheral neuropathy. Pes cavus can come from peripheral or central disease. There is no family history.

My differential includes a cerebellar tumor, multiple sclerosis, alcohol toxicity, B12 defic., as well as some inherited ataxias.

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