62-year-old male presents to primary provider’s office with a six-month history of fatigue and gait disturbance.  He denies recent falls, weakness, pain, paralysis, or dizziness.

Medications

Lisinopril 10mg daily

Metformin 1000mg BID

Men’s multivitamin

Fish oil

Past Medical History

Diabetes Mellitus II

Hypertension

Gastric cancer

Past Surgical History

Cholecystectomy – 1997

Partial gastrectomy – 2004

Vitals

BP-128/79, HR-81, RR-14, O2-100%, Temp-98.9^o

Physical Exam

General – WN/WD, NAD

Skin – scattered senile purpura, no petechiae

CV – RRR without M/G/R

Pulmonary – CTA bilaterally without adventitial breath sounds

Neurologic – A&Ox3, 5/5 strength throughout bilaterally, DTR 2+ and equal, FROM, vibratory sensation decreased in bilateral lower extremities

Laboratory Studies