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Does He Have Alzheimer's?

Physical Examination

Temp: 98°F
BP: 170/110
Pulse: 95
Resp: 19/min
Height: 5'11" Weight 293

HEENT: Within normal limits

Motor:

Biceps: 5/5 bilaterally
Triceps: 5/5 bilaterally
Quadriceps: 3/5 bilaterally
Hamstrings: 3/5 bilaterally

Sensory:

Pin-prick and temperature sensation and simple touch are intact. Vibration is normal in upper extremities, but diminished in lower extremities bilaterally.

Neurological

Reflexes:

Biceps: 2+ bilaterally
Brachioradial: 2+ bilaterally
Patellar: 3+ bilaterally
Ankle: 4+ bilaterally
Plantar Response: Extensor bilaterally

Proprioception and Cerebellar Function:

Finger to finger: normal
Heel to shin: normal
Rapid alternating movements: normal
Romberg: negative
Joint position: normal

Gait:

Mr. X's gait is abnormal, walking in a shuffling manner. He is mildly ataxic.

Cranial Nerves:

II-XII are intact.

Mental Status:

Patient seems confused. He is oriented to person, but not place or time. He exhibits dyscalculia. Remote memory is intact, yet immediate recall is impaired. When asked to act out combing his hair or shaving, the patient could not do so. Complex commands were difficult for the patient to follow. Judgment was impaired as was the ability to describe simple analogies.