CC: Having trouble speaking History of Present Illness A 74-year-old man is brought in by his son with complaints of spe

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CC: Having trouble speaking History of Present Illness A
74-year-old man is brought in by his son with complaints of speech
changes over the past 6 months. The patient denies significant
change in voice, but his son provides history that his father’s
voice has grown softer, speech is now slowly produced, and it is
difficult to understand him at times. These changes have made
communication over the phone particularly challenging. The
patient’s son lives out of state, so he had not seen his father in
person for about 8 months—but they speak on the phone frequently.
The son tells you that he was a bit surprised upon seeing his dad
because he noted not only the voice and speech-pattern changes but
he also seems to be moving a lot slower. The patient denies
experiencing any falls in the last year. Review of Systems Positive
for skin dryness and vivid dreams.
ROS is negative for anxiety, depression, weight loss, or
fatigue. No recent or other trauma stated. He is negative for head
injuries recently or in the past. No numbness, tingling, or
paresthesia in the hands.
Past Medical History The patient denies the use of prescription
medications or chronic medical conditions. He takes a men’s daily
multivitamin but no other supplements. Social history includes one
3-ounce-serving of whiskey each night before bed. Alcohol does not
seem to affect the tremor. He was a tobacco smoker, 1 pack per day
for 15 years but quit 25 years ago. He denies illicit drug use now
or in the past. He denies exposure to neurotoxins or other
chemicals.
Family history includes mother, deceased, at age 94, natural
causes; father, deceased, at 56, motor vehicle accident; a younger
sister, 68, with hyperthyroid and depression, which are managed;
one adult son, an adult daughter, and three granddaughters, all
healthy. He has been a widow for 3 years. He denies any family
history of ENT or neurological issues. Allergies—Penicillin
(hives); no known food allergies. Medications--Men’s daily
multivitamin, generic.
Vitals: T 98.6°F, P 78, R 22, BP: 110/78, HT: 72 in.; WT: 177
lbs.; BMI 24.
General: Well-nourished, good hygiene, no acute distress,
decreased spontaneous facial expressions.
Psychiatric: Able to follow commands, cooperative with a
physical exam, slow to answer history questions.
Skin, Hair, and Nails: Scaly, oily skin present around the nasal
labial folds and eyebrows.
ENT/Mouth: Voice quality poor (low volume); speech lacks
spontaneity and fluidity when produced; extraocular movements
intact in six cardinal positions of gaze.
Musculoskeletal: 5/5 strength in bilateral upper and lower
extremities; no atrophy of musculature or reduced range of
motion.
Neurologic: DTRs 2+ equal and symmetrical in bilateral upper and
lower extremities; positive for glabellar reflex; no increased tone
through passive motion in left upper extremity or bilateral lower
extremities; right upper extremity exhibits cogwheeling at the
wrist and elbow that worsens with distraction; supination-pronation
tremor noted at rest in the right hand; slight jaw tremor noted;
gait/balance assessment: patient needed three attempts to rise from
the chair using hands, positive retropulsion test, shuffling gait
present with reduced stride length; reduced arm swing in the right
arm on ambulation; negative Romberg sensation intact to light and
sharp touch on plantar surfaces of feet bilaterally; writing
assessment: handwriting is small and illegible, impaired ability to
copy a spiral (patient’s rendition appears smaller with less fluid
lines compared to provider’s example); rapid alternating movements
impaired in the right upper extremity; Mini-Mental score =
28/30.
Working Diagnosis?
Differential Diagnoses?
Initial Treatment Plan?
Education?