A 90-year-old Man With Dysphagia and Extremity Weakness
A neurology consult was requested for a 90-year-old, right-handed black man with a 6- to 8-week history of difficulty swallowing both solid and liquid foods. He was recently treated for aspiration pneumonia. Before involvement of the neurology department, speech therapists performed a video swallow evaluation that revealed lack of bolus transit through the pharynx.
The patient also reports 8 to 9 months of progressively worsening lower extremity weakness (he started using a walker at least 5 years ago). He also mentions 3 to 4 months of progressively developing weakness in both hands, with the left worse than the right. He reports no double vision, blurred vision, slurred speech, face numbness, or extremity numbness. He does not report bowel incontinence but has an indwelling catheter from being bed-bound over the past several months.
The patient's medical history is significant for hypothyroidism, hyperparathyroidism, hyperlipidemia, hypertension, chronic obstructive pulmonary disease, coronary artery disease with coronary artery bypass graft, monoclonal paraproteinemia, and lower lumbar laminectomy. He previously underwent successful surgery for squamous cell cancer of the right vocal cord and had a prostatectomy for prostate cancer. The patient takes levothyroxine, 0.075 mg daily; tramadol, 50 mg every 8 hours; and valsartan, 40 mg daily. He is a World War II veteran and has retired from the nursing department. He does not smoke or drink alcohol.
On admission, vital signs and general physical examination were within normal limits. Neurologic examination revealed an alert and oriented man with normal speech, language, and cognitive functions. Cranial nerve examination revealed minimally reduced elevation of the uvula and palate in a symmetrical fashion; the rest of the cranial nerves were normal. Motor examination revealed non-fluctuating muscle weakness with bilateral wrist and finger flexors at 3-4/5, bilateral triceps (4/5, left side weaker than right), 1/5 hip flexion, 2/5 knee extension with knee flexion 4/5, and left foot dorsiflexors 4/5. The remainder of muscle strength is 5/5, with muscle stretch reflexes of 0-1 in all 4 extremities. Sensory examination revealed reduced pin sensation bilaterally up to the midshin and normal proprioception. No pathologic reflexes were seen.
A 90-Year-Old Man With Dysphagia
A neurology consult was requested for a 90-year-old, right-handed black man with a 6- to 8-week history of difficulty swallowing both solid and liquid foods. He was recently treated for aspiration pneumonia. Before involvement of the neurology department, speech therapists performed a video swallow evaluation that revealed lack of bolus transit through the pharynx.
The patient also reports 8 to 9 months of progressively worsening lower extremity weakness (he started using a walker at least 5 years ago). He also mentions 3 to 4 months of progressively developing weakness in both hands, with the left worse than the right. He reports no double vision, blurred vision, slurred speech, face numbness, or extremity numbness. He does not report bowel incontinence but has an indwelling catheter from being bed-bound over the past several months.
The patient's medical history is significant for hypothyroidism, hyperparathyroidism, hyperlipidemia, hypertension, chronic obstructive pulmonary disease, coronary artery disease with coronary artery bypass graft, monoclonal paraproteinemia, and lower lumbar laminectomy. He previously underwent successful surgery for squamous cell cancer of the right vocal cord and had a prostatectomy for prostate cancer. The patient takes levothyroxine, 0.075 mg daily; tramadol, 50 mg every 8 hours; and valsartan, 40 mg daily. He is a World War II veteran and has retired from the nursing department. He does not smoke or drink alcohol.
Neurologic Examination
On admission, vital signs and general physical examination were within normal limits. Neurologic examination revealed an alert and oriented man with normal speech, language, and cognitive functions. Cranial nerve examination revealed minimally reduced elevation of the uvula and palate in a symmetrical fashion; the rest of the cranial nerves were normal. Motor examination revealed non-fluctuating muscle weakness with bilateral wrist and finger flexors at 3-4/5, bilateral triceps (4/5, left side weaker than right), 1/5 hip flexion, 2/5 knee extension with knee flexion 4/5, and left foot dorsiflexors 4/5. The remainder of muscle strength is 5/5, with muscle stretch reflexes of 0-1 in all 4 extremities. Sensory examination revealed reduced pin sensation bilaterally up to the midshin and normal proprioception. No pathologic reflexes were seen.
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