HISTORY OF PRESENT ILLNESS:

This 57-year-old right-handed African-American female was admitted to the Neurology Service for evaluation of right upper limb weakness and clumsiness.  The patient indicated that her symptoms began 3 years prior to admission, when she noted the gradual onset of gait unsteadiness and loss of balance.  Over the past 3 years, these symptoms have slowly progressed.  In addition to unsteadiness when walking, the patient gradually noted clumsiness with both upper limbs and slurring of her speech.  More recently, she noted difficulties with swallowing.  She denied diplopia, vertigo, weakness, sensory symptoms, or abnormal involuntary movements. 

Two years prior to admission, her primary care physician indicated to her that he thought she “had a stroke”.  The patient indicated that no other member of her family exhibited similar symptoms.   

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  No deficits of orientation, speech, or memory were present.  The patient’s mood was judged to be normal. 

Cranial Nerves:  Sensation of smell and visual acuity were not tested.  Visual field and funduscopic examinations were unremarkable.  External ocular movements were full without nystagmus or diplopia.  Pupils were equal, round, and reactive to light.  Sensory and motor functions of the Vth cranial nerve were normal.  There was no facial weakness.  Hearing was intact bilaterally.  XIth cranial nerve functions were normal.  The palate contracted symmetrically, and the uvula remained in the midline with vocalization.  The tongue protruded in the midline and showed no evidence of atrophy or fasciculation.  The patient’s speech was slow and slightly slurred.  She spoke slowly, as if attempting to enunciate each syllable individually. 

Motor System:  There was no evidence of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone and power were normal in all four limbs.  There were no spontaneous involuntary movements seen.   

Reflexes:  Deep tendon reflexes were equal and symmetric, and the plantar reflexes were flexor bilaterally.

Sensory System:  All modalities of sensation, including cortical sensations, were perceived normally. 

Cerebellar Function:  Cerebellar testing revealed an intention tremor in all four limbs with finger-to-nose and heel-to-shin testing.  Dysmetria was present in all four limbs.  Rapid alternating movements were produced dysrhythmically in all four limbs.