1) I need some help with this case.

45y male presents with sudden onset worsening of his balance while walking * past few months.

The problem had started insidiously, around 4 years ago when he noticed that he found himself staggering while walking.
2) This progressively worsened over the next 1 year while he also developed difficulties with buttoning shirts and eating meals with hands.

This was associated with tingling and numbness of all 4 limbs, which began in the hands and feet and then progressed upto thighs and arms.
3) It was a problem of balance, he says, where his fingers seem to fly off target rather than inability to force his muscles according to him.

No h/o sudden give away or stiffness.

No headache, abn behaviour, fits, visual abn, double vision, bladder bowel abn or abn movement.
4) He is a known drinker and has consumed almost half a bottle each day since he was 20. No other addiction.

No other signficant medical or surgical history.

No significant family history among his 1st degree relatives.
5) Clinical exam is done.

Gen survey - unremarkable

Neuro exam
Higher mental function - grossly N
CN - no abn detected
Motor - no atrophy or fasciculations, tone N, power 5/5 in all muscle groups
DTR - all absent (with Jendrassik)
6) Sensory
Pinprick and temperature sensation preserved
JPS impaired at toes and ankles in LL and fingers and wrists in UL --> we couldn't test beyond that because of confounding due to touch.
Vibration sense - impaired upto clavicles.
Tandem gait - not possible
Romberg +
7) Cerebellar exam
- as mentioned in CN, no nystagmus or abn with saccade or pursuit
- no titubation, scanning speech
- truncal ataxia on standing or sitting, broad based gait with marked worsening on eye closure
- B/L finger nose+ with kinetic tremor, RAM+, heel shin+, rebound+
8) Autonomic testing not done.

Since I am an internist with much less experience in the neuro exam, I have gotten my findings rechecked by neurologists.
9) My question is where do I localize this lesion?
10) This is an interesting case that we have been mulling over for some time now.

Please provide your reasoning in the comments below!

Thank you very much!

11) I forgot to add --> he had classic pseudoathetosis ie piano key movements of both fingers and toes.
12) Big mistake -- hope the neurologists don't kill me :D

B/L plantars were flexor.

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