Case 4
CASE 4: DESCRIPTION
62 year-old right handed woman presents to neurology clinic for intermittent tremor of the left arm followed by trouble walking. The tremor does not bother her but her friends have pointed it out and it is socially embarrassing. She notes that her left leg drags a bit when walking starting gradually over the last year or two. It feels stiff, slow and sometimes almost stuck to the floor when attempting to ambulate.
SHx: identifies as Black, retired professor, 1-2 glass of wine/week
Review of systems: positives include constipation, left shoulder stiffness, constipation, anosmia, acting out dreams at night
Vitals: T 36.8, BP 115/80, HR 70, RR 12, O2 sat 99% RA.
General Exam: appears stated age, pleasant, well-groomed
HEENT: decreased blink rate
Neurologic Exam:
Mental status: Alert, oriented x 3, speech is fluent and conversant, able to name and repeat but with bradyphrenia. Mild hypophonia.
CN: masked facies, VFFTC, EOMI but saccadic intrusions with smooth pursuit noted during extraocular movement testing, face symmetric and strong, tongue midline and strong without fasciculations
Motor: increased tone in left upper extremity and left lower extremity. The tone is increased throughout the movement, not velocity dependent. Strength is 5/5 throughout. Mild resting tremor noted in left hand that resolves with posture or movement. Bradykinesia most notably on the left arm with slowness and decreased amplitude with finger tapping; slight decreased amplitude and dysrhythmia of left foot taps
Sensation: normal to all modalities
Reflexes: 2+ and symmetric, toes down
Coordination: Normal finger-to-nose, heel-knee-shin
Gait: decreased arm swing on left. One episode of freezing of gait while crossing doorway threshold. Festinating, slightly stooped, multiple steps required when turning. No postural instability with pull test