A 65-year-old man comes to the physician's office because of frequent falls

A 65-year-old man comes to the physician’s office because of frequent falls. For the past 2
months, he has been having increasing difficulty in maintaining balance when walking or
standing He tends to lose his balance on the left side, and feels that his “left body has become
weak.” He also complains of occasional headaches and nausea for the past 3 months. His other
medical problems include hypertension, diabetes mellitus-type 2 and a myocardial infarction 10
years ago He denies the use of tobacco, alcohol, or drugs His medications include glyburide,
aspirin and enalapril His vital signs are within normal limits. When asked to get up from the
chair and stand with his feet together, he tends to sway to the left, even with his eyes open.
When asked to walk a few steps, he walks cautiously and lurches to the left. There is decreased
resistance to passive flexion. Which of the following is the most likely diagnosis?
6 A Major depression
<0 B. Huntington’s disease
6 C. Parkinsonism
® D. Tabes dorsalis
e; E. Hemiparesis
0 F. Adverse drug reaction
<0 G. Muscular dystrophy
<0 H. Cerebellar tumor
6 I. Normal pressure hydrocephalus

Explanation:
The most likely diagnosis is a cerebellar tumor, which typically presents with ipsilateral ataxia,
especially if it is located within the hemisphere The patient tends to fall towards the side of the
lesion. When asked to stand with his feet together, the patient also tends to sway to the affected
side, and may exhibit titubation, which is a forward and backward movement of the trunk. Other
characteristic features of cerebellar tumors include nystagmus, intention tremor, ipsilateral
muscular hypotonia, and marked difficulty in coordination and performing rapid, alternating
movements. Obstruction of the CSF flow by the tumor results in increased intracranial pressure,
which may present as headaches, nausea, vomiting and papilledema
{Choice A) Major depression does not produce ataxia, and is therefore incorrect
{Choice B) Huntington’s disease is an autosomal dominant condition. Patients typically present
at approximately 40 years of age with chorea, personality changes and dementia.
(Choice C) The hallmarks of Parkinsonism include a mask-like, immobile facial expression,
bradykinesia, resting tremor, rigidity and festinating gait
{Choice D) Tabes dorsalis is a manifestation of neurosyphilis, which has now become rare
owing to early diagnosis and treatment Destruction of the posterior columns leads to loss of
proprioception The patient walks with his legs wide apart The feet are lifted higher than usual,
and make a slapping sound when they come in contact with the floor. Romberg’s sign may be
positive
(Choice E) Since the patient does not have a history of a stroke, hemiparesis is unlikely During
walking, the hemiparetic patient keeps his affected arm adducted, and the affected leg extended.
The leg is swung outward in a semicircle as the patient walks.
(Choice F) The patient’s current medications (ie , glyburide, aspirin, enalapril) do not have any
adverse effects on gait
~ (Choice A) Major depression does not produce ataxia, and is therefore incorrect
(Choice B) Huntington’s disease is an autosomal dominant condition. Patients typically present
at approximately 40 years of age with chorea, personality changes and dementia.
{Choice C) The hallmarks of Parkinsonism include a mask-like, immobile facial expression,
bradykinesia, resting tremor, rigidity and festinating gait
(Choice D) Tabes dorsalis is a manifestation of neurosyphilis, which has now become rare
owing to early diagnosis and treatment Destruction of the posterior columns leads to loss of
proprioception The patient walks with his legs wide apart The feet are lifted higher than usual,
and make a slapping sound when they come in contact with the floor. Romberg’s sign may be
positive.
(Choice E) Since the patient does not have a history of a stroke, hemiparesis is unlikely During
walking, the hemiparetic patient keeps his affected arm adducted, and the affected leg extended.
The leg is swung outward in a semicircle as the patient walks.
{Choice F) The patient’s current medications (ie. , glyburide, aspirin, enalapril) do not have any
adverse effects on gait
(Choice G) Muscular dystrophy results in a waddling gait owing to weakness of the gluteal
muscles.
(Choice I) Normal pressure hydrocephalus is characterized by dementia, gait ataxia and urinary
incontinence. The disorder is treated by surgical shunting of the CSF.
Educational Objective:
Cerebellar tumors usually produce ipsilateral ataxia, nystagmus, intention tremors, and loss of
coordination.
• Know the different types of gait and how to differentiate them based on the history and physical
examination.