A 73-year-old Caucasian man is brought to the office by his daughter, who is concerned that he might be depressed. He is a retired surgeon, and has lived alone ever since his wife died a year ago. His daughter visits him every 6 months; she feels bad about not being able to visit him more frequently because her job and family keep her very busy. He denies having any feelings of sadness, guilt, weight loss, loss of appetite, suicidal ideation, deafness, vertigo, and decreased or blurred vision. His medical problems include hypertension, diabetes mellitus-type 2 and a myocardial infarction 10 years ago. His current medications are glyburide, aspirin and enalapril. He denies the use of tobacco, alcohol, or drugs. His vital signs are within normal limits. He appears withdrawn, less energetic than usual, and walks stiffly. He sits with a stooped posture. He has a fixed facial expression, and his voice sounds monotonous. His deep tendon reflexes are 2+. Sensations and motor strength are normal. There is increased resistance to passive flexion. Which of the following types of gait is most likely to be present in this patient?

Question

A 73-year-old Caucasian man is brought to the office by his daughter, who is concerned that he might be depressed.  He is a retired surgeon, and has lived alone ever since his wife died a year ago.  His daughter visits him every 6 months; she feels bad about not being able to visit him more frequently because her job and family keep her very busy.  He denies having any feelings of sadness, guilt, weight loss, loss of appetite, suicidal ideation, deafness, vertigo, and decreased or blurred vision.  His medical problems include hypertension, diabetes mellitus-type 2 and a myocardial infarction 10 years ago.  His current medications are glyburide, aspirin and enalapril.  He denies the use of tobacco, alcohol, or drugs.  His vital signs are within normal limits.  He appears withdrawn, less energetic than usual, and walks stiffly.  He sits with a stooped posture.  He has a fixed facial expression, and his voice sounds monotonous.  His deep tendon reflexes are 2+.  Sensations and motor strength are normal.  There is increased resistance to passive flexion.  Which of the following types of gait is most likely to be present in this patient?

Quizplus · Accepted Answer

The most likely diagnosis of this patient is Parkinsonism. Hallmarks of this disease include a mask-like, immobile facial expression, bradykinesia, resting tremor, rigidity and festinating gait. There is a general slowing of all motor activity (hypokinetic gait). Patients assume a stooped posture, and walk in series of short, accelerating steps, such that the feet shuffle and scrape the floor. The arms remain immobile and do not swing during walking. The underlying pathology involves the degeneration of neurons in the substantia nigra, thereby leading to decreased dopaminergic activity and increased cholinergic activity. The diagnosis is made clinically. The treatment includes dopaminergic and/or anticholinergic drugs. (Choice A) Cerebellar ataxia is usually ipsilateral (i.e., the patient tends to fall towards the side of the lesion). Other features of cerebellar disorders include nystagmus, hypotonia, dysarthria, loss of coordination, and the inability to perform rapid, alternating movements. (Choice C) Muscular dystrophy results in a waddling gait owing to weakness of the gluteal muscles. (Choice D) Spastic gait is seen with lesions of the upper motor neuron (e.g., spinal cord injury or cerebral palsy). The movements of the affected extremities are slow, stiff, and effortful. (Choice E) Gait disequilibrium results from disorders of the frontal lobe and multiple sensory systems. (Choice F) Sensory ataxia is seen with lesions involving the peripheral nerves, dorsal roots or posterior columns. Loss of proprioception results in a wide-based, high-stepping gait. Romberg's sign may be positive (i.e., the patient sways on standing with his feet together and eyes closed). (Choice G) Vestibular ataxia results in an en-bloc gait, with minimal movements of the head during walking. It is typically a staggering gait, and is accompanied by vertigo and nystagmus. (Choice H) The hypokinetic gait in patients with Parkinsonism is typically narrow-based; therefore, a broad-based gait, in the presence of other clinical features suggestive of Parkinsonism, is ample reason to consider other syndromes such as multiple system atrophy, spinocerebellar atrophies, and multi-infarct gait disorders. Wide-based gait is also seen in sensory ataxia, some cerebellar disorders and muscular dystrophies. (Choice I) Dystonic gait is characterized by involuntary, sustained, twisting movements of the limbs and trunk. Educational Objective: Parkinsonism is caused by overactivity of cholinergic neurons and underactivity of dopaminergic neurons in the substantia nigra. A shuffling gait (i.e., the patient appears as if he was chasing his center of gravity) is characteristic of the disease.

A 73-Year-Old Caucasian Man Is Brought to the Office by His