NEUROLOGICAL:  As follows.  Right-handed female, normal orientation, normal recollection to 3 objects.  The patient has underlying MR. Speech, no aphasia, no dysarthria.  Cranial nerves, funduscopic intact without papilledema.  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  No nystagmus.  Her mood is intact.  Symmetric face sensation.  Symmetric smile and forehead.  Intact hearing.  Symmetric palate elevation.  Symmetric shoulder shrug and tongue midline.  Motor 5/5 proximal and distal.  The patient does have limp on the right lower extremity.  Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left.  Sensory, the patient does have sharp, soft touch, vibration intact and symmetric.  The patient has trouble with ambulation.  She does have ataxia and uses a walker to ambulate.  There is no bradykinesia.  Romberg is positive to the left.  Cerebellar, finger-nose-finger is intact.  Rapid alternating movements are intact.  Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding.  Neck more than 16 to 17 inches, BMI elevated above 33.  Head and neck circumference very high.