Clinical note section (GENHX): The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms.  I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems.  He first mentioned that he has neck pain.  He states that he has had this for at least 15 years.  It is worse with movement.  It has progressed very slowly over the course of 15 years.  It is localized to the base of his neck and is sharp in quality.  He also endorses a history of gait instability.  This has been present for a few years and has been slightly progressively worsening.  He describes that he feels unsteady on his feet and "walks like a duck."  He has fallen about three or four times over the past year and a half. He also describes that he has numbness in his feet.  When I asked him to describe this in more detail, the numbness is actually restricted to his toes.  Left is slightly more affected than the right.  He denies any tingling or paresthesias.  He also described that he is slowly losing control of his hands.  He thinks that he is dropping objects due to weakness or incoordination in his hands.  This has also been occurring for the past one to two years.  He has noticed that buttoning his clothes is more difficult for him.  He also does not have any numbness or tingling in the hands.  He does have a history of chronic low back pain. At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome.  He did not even mention this on the initial part of my history taking.  When I asked him to describe this further, he states that he experiences a general exhaustion.  He basically lays in bed all day everyday.  I asked him if he was depressed, he states that he is treated for depression.  He is unsure if this is optimally treated.  As I just mentioned, he stays in bed almost all day long and does not engage in any social activities.  He does not think that he is necessarily sad.  His appetite is good.  He has never undergone any psychotherapy for depression. When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past.  I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago.  He states that the results were normal and that specifically he did not have any dementia. When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago.  He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes.  He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation.  He also saw Dr. Z for neurosurgical consultation a couple of weeks ago.  He reports that she did not think there was any surgical indication in his neck or back at this point in time.

Dialogue:
Doctor: Welcome back, sir! 
Patient: Thank you. 
Doctor: Today we are following up on several neurological symptoms that you have been experiencing. 
Patient: Okay. 
Doctor: What hand is your dominant hand? 
Patient: I am left handed. 
Doctor: And you are sixty three years old, right? 
Patient: That's right! 
Doctor: I would like to discuss each one of your multiple symptoms individually.
Patient: I have this pain in my neck. 
Doctor: Is the neck pain a new symptom? 
Patient: No. I have had this pain for. Oh, maybe fifteen years. At least. 
Doctor: Has the pain been progressing over the years or has it been the same? 
Patient: It is worse right now. 
Doctor: When did the pain become worse? 
Patient: I don't know. It has been getting more painful since it started. Little by little. 
Doctor: Where is the pain? 
Patient: It's in my neck. 
Doctor: Can you show me where the pain in the neck is coming from?
Patient: It is coming from this area right here. 
Doctor: Right at the base of the neck then? 
Patient: Yeah, I guess. 
Doctor: What does the pain feel like? 
Patient: It hurts.
Doctor: Mean is the pain sharp or dull? 
Patient: It is sharp. 
Doctor: Okey. Do you have any problems with your mobility? 
Patient: Yes. I am a bit unsteady on my feet. I walk like a duck. 
Doctor: How long have you been experiencing this for? 
Patient: It had been a few years. 
Doctor: Has it become worse over that time? 
Patient: A little. I am so clumsy now. I fell about three or four times recently. 
Doctor: How recently? 
Patient: I have been no feeling in my, um feet.
Doctor: Can you describe it? Is it numbness? 
Patient: I said, no feeling. 
Doctor: What part of your feet is it affecting? 
Patient: It is not the whole foot. Just the toes. The left toes are worse than the right ones. 
Doctor: Let me take a look. I am just going to remove your socks.
Patient: Okay. 
Doctor: How long has this been happening? 
Patient: I don't know. Maybe a year or no, um.  I think maybe the last year and a half.
Doctor: Have you had any tingling or abnormal sensations? 
Patient: No. I said no feeling. 
Doctor: Can you feel this? 
Patient: No. 
Doctor: How about this? 
Patient: Yes, a little.
Doctor: How has your back been feeling? 
Patient: It is the same. It's still here in my low back. 
Doctor: Do you have any other concerns today? 
Patient: I have been dropping things. 
Doctor: What do you mean dropping things? 
Patient: I can't hold on to things. I drop things. I grab on to something and then I can't keep ahold of it. 
Doctor: How long has this been happening for? 
Patient: Um. I guess the same amount of time. 
Doctor: The same amount of time as your feet? 
Patient: Yes. A year or two. I wasn't always this bad. It has been getting worse this whole time. 
Doctor: So, it has been getting worse with time. 
Patient: Yes. I am slowly losing control of my hands. Buttoning my clothes is really hard for me now.  
Doctor: I am so sorry to hear that. Have you had any tingling or numbness in your hands? 
Patient: No. I just can't do things like I used to. 
Doctor: Which one of your symptoms is the most bothersome to you? 
Patient: The most? Um well, I am really worn down all the time. 
Doctor: Can you elaborate on the worn down? 
Patient: I am exhausted all the time for no reason or the other. 
Doctor: I am glad you mentioned this to me before I let you go today. 
Patient: Yeah. All I do is just lay in bed all day everyday. 
Doctor: Are you having feelings of depression? 
Patient: Yes, I have depression. 
Doctor: Are you being treated for your depression? 
Patient: Yes. I don't think that it is working. I mean, all I do is stay in bed all day. 
Doctor: Do you have any company or do any socializing? 
Patient: No. I don't ever feel like it anymore. I am exhausted! I am not necessarily sad. 
Doctor: How is your appetite? 
Patient: Appetite? 
Doctor: Yes. Have you been eating well? 
Patient: No problem there. 
Doctor: Have you ever seen a psychotherapist for your depression?
Patient: Psychotherapist?
Doctor: Like a therapist or a counselor? 
Patient: No nothing like that.
Doctor: I noticed that your responses are a little bit delayed and you're having difficulty with your memory. Have you ever been evaluated for cognitive difficulties? 
 Patient: Um they did a test. 
Doctor: Who did a test? How long ago was that? 
Patient: Um, it was at the Hopkins place. 
Doctor: John Hopkins? 
Patient: Yeah, that's the one. It was a couple of years ago.  
Doctor: What were the results of the test that they did?
Patient: Normal. A guy said that, that I don't have dementia.
Doctor: He said that specifically? 
Patient: Yeah, that's what he said no dementia. I first saw Doctor X years ago he told me I had something called, neuropathy because of my diabetes. I am not sure what that is.
Doctor: How long ago was that?
Patient: A very long time ago. And then I just saw that other doctor oh what's his name it starts with a Y. Doctor Y this time. 
Doctor: Hum? 
Patient: I also saw the neuro guy. My new one. That was a couple of weeks ago.
Doctor: What is his name?
Patient: Whose name?
Doctor: The neuro guy you saw a couple of weeks ago?
Patient: Oh, I can't remember maybe Doctor Z I think.
Doctor: What did this Doctor Z say after your evaluation?
Patient: He said he didn't think I need surgery on my neck or back at this time.
Doctor: Okey