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SECTION 1 A 72-year-old right-handed man with a history of coronary artery disease, aortic valve replacement, and hypothyroidism presented with 3 years of progressive difficulty using his right upper extremity, which had resulted in a largely nonfunctional limb within a year. In contrast, he reported relatively intact left up- per limb function. He had developed gait instability within 6 months of onset and by 2 years he was nonambulatory. He reported slurring of speech and difficulty moving his eyes to either side, but espe- cially to the right. He denied visual loss, diplopia, cognitive decline, visual hallucinations, sensory loss, autonomic symptoms, sleep disturbance, or percep- tion of an alien limb. There had only been a nonsus- tained levodopa response. His medications included atenolol, monopril, simvastatin, warfarin, and levo- thyroxine. There was no family history of neurologic disease. He denied toxic exposures and had a distant history of tobacco use. On examination, he was not orthostatic. He was fully oriented, could recite the months backwards, and had fluent speech and normal comprehension and naming. He recalled 2 out of 3 words after 5 minutes. He accurately drew a clock. He required 3 attempts to correctly imitate the Luria 3-step test (normal 2 attempts) and he could not sustain the sequence. The go-no go task consistently showed er- rors of commission and he was concrete with proverb interpretation.

Clinical Reasoning: A video analysis of eye and limb movement abnormalities in a parkinsonian syndrome