This 64-year-old man indicated that he was falling, he thinks, because he was off balance, seemed to fall forward. There was some suggestion on exam that he had some mild parkinsonian symptoms, and since he was taking Reglan at the time, it was considered that he might be evolving side effects of Reglan, and it was recommended that this be discontinued and it was. He indicates when he falls down now he cannot get back up and has to have someone help him. Admits he has frequent dizzy spells, particularly when he first stands up. Wife feels his speech has become slurred since this fall. He says he does not think there has been any change in his speech with regards to slurring, but that he has had some trouble for a time now in trying to remember proper words to express his thoughts. He denies any other problems with his memory. Review of other neurologic symptoms reveals no significant problem with headaches. He has lost vision in his left eye due to retinopathy and reports that his right eye now gives him difficulty, and it is hard for him to read. He is not aware of ever having had any epileptic seizures. His wife gave a history that he had had some swallowing problems recently.
PHYSICAL EXAMINATION
Physical exam revealed an alert, cooperative, oriented man who does not appear to be in acute distress at this time. Intellectual function testing grossly suggests the patient may have some mild problems with memory, but he recalled me and my name when I first walked into the room, and he certainly is well oriented. He is right handed. Speech may be very slightly slurred. No evidence of aphasia is noted. Examination of the skull and spine is unremarkable. Specifically there is no tenderness anywhere in the spine. Neck vessels are unremarkable.
CRANIAL NERVES: 1: Not tested. 2: Visual acuity; right eye appears to be reasonably intact on bedside testing. Left eye: He cannot even see movement. Right fundus only can be seen and shows changes of diabetes but otherwise unremarkable. 3, 4, and 6: Movement of the right eye appears to be intact. The right pupil reacts sluggishly to light. There is no reaction of the left pupil. 5: Normal motor and sensory function. 7: There appears to be a very slight drooping of the left corner of the mouth. 8: Hearing is grossly intact. 9 and 10: Uvula is in midline. Palate moves symmetrically. 11: Sternomastoid and trapezius muscles appear to contract well. 12: Tongue protrudes in midline. Movements are intact. No wasting.
MOTOR SYSTEM: No deformities noted. He has some significant wasting of the muscles of both hands. On testing strength he has a mild to moderate weakness of the extremities, particularly distally and symmetrically. Deep tendon reflexes are absent throughout. He was noted at times to have some jerking myoclonic-type of movements in his upper extremities, particularly the left. Patient was not gotten up to test stance or gait at this time.
SENSORY EXAM: Has decreased pin sensation, stocking-glove fashion, up to about the wrists and the hands, to just about the knees and the legs. This was for pain sensation. Joint position sense appears to be intact.
IMPRESSION
The patient has a fairly severe diabetic neuropathy causing postural hypotension. I suspect this is the major reason for his falling. I certainly agree that an magnetic resonance imaging is indicated at this time to investigate for the possibility of recent cerebrovascular accident but suspect his peripheral neuropathy and postural hypotension are going to be the main causes of his difficulties.
FOOTNOTE
Lines 10-13 (Page 1). The dictator’s awkward phrasing was edited.
Line 28 (Page 1). Exam was expanded to Examination in the heading.
Lines 19 (Page 2). The abbreviation MRI was expanded in the Impression for clarity.
Line 23 (Page 2). Cause was changed to causes for plural agreement (neuropathy and hypotension are causes).
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