HPI
This 48-year-old RH engineer was accompanied by his wife. He reported the gradual onset of slowness of movement over the last year. It was more difficult to get in and out of the car and to roll over in bed. His coordination had decreased somewhat as well, and complained of clumsiness and some difficulty with writing. He admitted to feeling somewhat depressed over the last year, and his wife stated that he seemed withdrawn and less attentive about his appearance, and that she had noticed these changes for at least 2 years. He had been treated with antidepressants but with little benefit. He denied any tremor, difficulty with balance or involuntary movements, but his wife noted some twitching around his mouth and an odd posture of his left arm when he was walking.
PMH
He had no history of other medical problems, and no history of head trauma or drug abuse.
FH: The patient was adopted.
PE
- Gen: a well-developed man who was slightly disheveled. His vitals signs were normal, and he had no abnormalities of heart or pulmonary exam.
NEURO
- MS: The patient was awake and alert. His facial expression was somewhat flat and his blink rate reduced. His speech was somewhat soft but clear; he was somewhat slow to answer questions. His mental status testing revealed normal orientation, immediate and delayed recall and concentration. He had no language difficulties.
- CN: Normal fundoscopy and visual fields. His extraocular movements were normal for pursuit movements, but there was slow initiation of horizontal and vertical sacaades. He had normal facial sensation and no weakness of facial muscles. Hearing was intact. He had normal palatal elevation and gag reflex, but there were some irregular movements of his tongue when protruded. There were no tongue fasciculations.
- Motor: Some rigidity of neck muscles, and slight cogwheeling in the left upper extremity. There was mild slowness and irregularity of finger tapping and hand movements bilaterally. Strength was normal.
- DTR’s were 2+ in the upper extremities and 3+ in the lower extremities. Plantar reflexes were flexor. There were no frontal release signs.
- Sensation: Intact for pinprick, vibration and proprioception.
- Cerebellar: Coordination tests showed slowness and irregularity of rapid alternating movements and heel to shin testing bilaterally.
- Gait: Slowness in arising from the chair. His gait was slightly slow and wide based. There was reduction of arm swing bilaterally, and there was a extended position of the left hand and elbow while walking. He had difficulty performing the tandem gait maneuver, and he tended to retropulse when pulled backward.
Study Questions:
- Summarize the key points of the history.
- Summarize the key findings of the physical exam.
- Localize the site of the neurological signs and symptoms.
- What neuroimaging tests should be performed? What findings would you expect to see?
- Should any laboratory tests be done?
- What recommendations would you make to this patient’s family?
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