47M with Involuntary Hand Movements

  NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

CHIEF COMPLAINTS:

A 47 year old male presented with chief complaints of:

• Involuntary movements in hands and feet since 3-4 yrs

• Inability to talk properly since 3 years

• Difficulty in swallowing since 2 years

• Urinary incontinence

HISTORY OF PRESENTING ILLNESS:

CRANIAL NERVE	TEST	RIGHT	LEFT
I	Sense of smell i)               Coffee	+	+
II	i) Visual acuity – Rosenbaum Chart	20/20	20/20
III, IV, VI	i)               Extra-ocular movements ii)             Pupil – Size iii)           Direct Light Reflex iv)            Consensual Light Reflex v)             Accommodation Reflex vi)             Ptosis vii)    Nystagmus viii)  Horners syndrome	full 3 mm Present Present Present Absent Absent No	full 3 mm Present Present  Present Absent Absent No
V	i) Sensory -over face and buccal mucosa ii) Motor – masseter, temporalis, pterygoids iii) Reflex a.     Corneal Reflex b.     Conjunctival Reflex c.     Jaw jerk	Normal Normal   Present Present Present	Normal Normal   Present Present Present
VII	i) Motor – nasolabial fold hyeracusis occipitofrontalis orbicularis oculi orbicularis oris buccinator platysma ii) Sensory – Taste of anterior 2/3rds of tongue(salt/sweet) Sensation over tragus iii) Reflex – Corneal Conjunctival iv) Secretomotor – Moistness of the eyes/tongue and buccal mucosa	Present Absent Good Good Good Good Good   Normal   Normal   Present Present   Normal	Present Absent Good Good Good Good Good   Normal   Normal   Present Present   Normal
VIII	i) Rinnes Test ii) Webers Test     iii) Nystagmus	Positive Not lateralised   Absent	Positive       Absent
IX, X	i) Uvula, Palatal arches, and movements     ii) Gag reflex iii) Palatal reflex	Centrally placed and symmetrical   Present Present	Present Present
X1	i) trapezius ii) sternocleidomastoid	Good Good	Good Good
XII	i) Tone ii) Wasting iii) Fibrillation iv) Tongue Protrusion to the midline and either side	Normal No No Normal	Normal No No Normal

TEST	RIGHT	LEFT
I – BULK a.     Inspection b.     Palpation c.     Measurements Upper limb – 10cm above and below acromion Lower limb 18 cm above and 10 cm below tibial tubercle	Slightly decreased Slightly decreased 29 cms         32 cms	Slightly decreased Slightly decreased 29 cms 32 cms (?)
II – TONE a.     Upper limbs b.     Lower limbs	Normal	Normal
III – POWER a.     Neck muscles b.     Upper limbs i)               Shoulder Flexion-Extension Lateral Rotation-Medial Rotation Abduction -Adduction ii)             Elbow Flexion-Extension iii)           Wrist Dorsi flexion-Palmar flexion Abduction-Adduction Pronation-Supination iv)       small muscles of hand v)        Hand grip   c.     Lower limbs i)               Hip Flexion-Extension Abduction-Adduction Lateral Rotation-Medial Rotation ii)             Knee Flexion-Extension iii)           Ankle Dorsi flexion-Plantar flexion Inversion-Eversion iv)        Small muscles of foot   d.     Trunk muscles	Good   5/5 5/5 5/5 5/5   5/5   5/5 5/5 5/5 Good Good       5/5 5/5 5/5   5/5   5/5 5/5 Good   Good	Good   4/5 4/5 4/5 4/5   4/5   4/5 4/5 4/5 Good Good       5/5 5/5 5/5   5/5   5/5 5/5 Good   Good
IV – REFLEXES A.    SUPERFICIAL REFLEXES 1.     Corneal 2.     Conjunctival 3.     Pharyngeal Reflex 4.     Palatal Reflex 5.     Abdominal Reflex 6.     Cremasteric Reflex 7.     Perianal Reflex 8.     Plantar Reflex B.    DEEP TENDON REFLEXES 1.     Jaw jerk 2.     Trapezius jerk 3.     Pectoralis jerk 4.     Biceps jerk 5.     Triceps jerk 6.     Supinator jerk 7.     Finger flexion reflex 8.     Knee jerk 9.     Ankle jerk 10.  Clonus	Present Present Present Present Present Present Present Flexor   Present Present Present Present Present Present Present Present Present Absent	Present Present Present Present Present Present Present Flexor    Present Present Present Present Present Present Present Present Present Absent
V – COORDINATION TESTED ALONG WITH THE CEREBELLUM
VI – GAIT
VII – INVOLUNTARY MOVEMENTS A – Athetosis C – Chorea F – Fasciculations

TEST	RIGHT	LEFT
I – SPINOTHALAMIC 1.     Crude touch 2.     Pain 3.     Temperature II – POSTERIOR COLUMN 1.     Fine touch 2.     Vibration 3.     Position sense 4.     Romberg’s sign III – CORTICAL 1.     Two point discrimination 2.     Tactile localisation 3.     Graphaesthesia 4.     Stereognosis	Normal Normal Normal   Normal Normal Normal Absent   Normal Normal Normal Normal	Normal Normal Normal   Normal Normal Normal Absent   Normal Normal Normal Normal

x

1. WEAKNESS OF LIMBS

a.     Weakness of all limbs since 2 years, insidious in onset, gradually progressive and simultaneous in all limbs.

1.     Upper limbs

i)    Has no difficulty in combing hair, taking the food to the mouth

ii)   Has no difficulty in buttoning the shirt, mixing the food

2.     Lower limbs

i)        Has difficulty squatting and getting up from the squatting position, 

ii) Has no difficulty climbing stairs up and down

iii)       Has history of slipping of chappals, 

iv)       No history of tripping of toes

g.     No difficulty in lifting the head off the pillows

h.     No difficulty in Rolling over the bed, getting up from the bed

i.       No Difficulty in breathing

j.      No diurnal variation in weakness

2. SPINOMOTOR SYSTEM

a.     Wasting/Thinning of muscles since 1 year in hands, trunk, lower limbs subjectively

b.     No Pain/ fatigue/ muscle cramps

c.     Fasciculations/muscle twitchings in toes and B/L fingers

d.     Involuntary movements – chorea & athetosis present

3. SENSORY SYSTEM

a. Pain at the nape of the neck

b. No pins/needles

c. No unsteadiness

4. HIGHER MENTAL FUNCTIONS

a. No loss of consciousness

b. Slurring of speech (?) while speaking fast

c. Bladder - Uncontrolled urination since 3-4 yrs

d. Bowel movements increased since 3-4 yrs (3-4 episodes a day)

e. Memory - Decreased short-term memory since 5-6 yrs

f. No delusions/ Hallucinations/emotional disturbances

5. CRANIAL NERVES

I – No alteration in smell

II – No blurring of vision/diminished vision, night blindness, able to differentiate colours

III, IV, VI – No drooping of eyelids/ double vision/ able to move eyes in all directions

V – Having sensation over the face, able to chew food

VII – able to close the eyes and lips,  able to feel taste of objects, No deviation of angle of mouth, or drooling of saliva

VIII – No hard of hearing, tinnitus, vertigo

IX, X – Slight slurring of speech, difficulty in swallowing and h/o nasal regurgitation of liquids

XI – move the neck in all directions, lift the shoulder

XII – able to roll the tongue and push the food backwards

6. CEREBELLUM

a. No spilling of food while taking to the mouth, clumsiness of hands

b. No unsteadiness while walking and swaying to sides

c. No abililty to negotiate narrow pathways

7. AUTONOMIC NERVOUS SYSTEM

a. bladder – able to feel bladder fullness, initiate micturition, feel the passage of urine, unable to hold urine midstream, not able to completely evacuate the bladder, no dribbling

b. bowel – Increased bowel movements since 3-4 yrs (3-4 times a day)

c. No giddiness on getting up in the morning

d. No sweating disturbances, palpitation

8. MENINGES

No Fever, vomiting, stiffness of neck

No relevant negative history or past history

PERSONAL HISTORY:

a.     Married 

b.     Non- veg

c.     Smoking - 1-2 cigarettes a day

e.     Alcohol - occasionally

f.      Drug abuse - No

g.     Exposure - No

FAMILY HISTORY:

PHYSICAL EXAMINATION

 

GENERAL EXAMINATION:

Patient is conscious, oriented, Comfortable, Co-operative

Moderately Built

Moderately Nourishment

Febrile

No Palor

No Icterus

No Cyanosis 

No Clubbing 

No Pedal edema 

No Significant lymphadenopathy

Right handed 

VITAL SIGNS

 

PULSE: rate, rhythm, volume, character, felt in all peripheral pulses/not, radioradial/radiofemoral delay, apex pulse deficit, condition of vessel wall

 

BLOOD PRESSURE: 110/70 mm of Hg 

 

RESPIRATORY RATE: 20/min, regular

 

TEMPERATURE: 96 F measured in the Axilla

 

NEUROLOGICAL EXAMINATION

 

1.     HIGHER MENTAL FUNCTIONS:

a.   Conscious, Orientation to time, place and person

c.   Speech and language –  aphasia, dysarthria, dysphonia

d.   Memory - 

        Short term - Patient was asked to recollect what he had for breakfast in the morning, to name a significant thing that happened in the last 1 week, what he ate yesterday, etc. - he had some difficulty recollecting these

        Long term - Patient was asked to recollect his date of birth, name of school, anniversery date, etc. He had no difficulty in doing this

e.  No Delusions, hallucinations

f.     MMSE score

I. Orientation

    1. date, day, month, season, year - 5

    2. floor, hospital. District, state, country - 5

II. Registration

    Named three objects taking one second for each object - bed, bottle, pen 

Asked him to repeat the same. He was able to repeat it. (3)

  

III. Attention and Calculation

     Serial 7’s 5 times - 3 - had slight difficulty in counting back serial 7s (3/5)

IV. Recall

     Recall the three objects - He was able to recall all the objects (3)

V. Language

     1. Name 2 objects (2)

     2. Repeat a sentence (1)

     3. Follow a 3 stage command (3)

     4. Reading “close your eyes”(1)

     5. Writing a sentence (1)

     6. Copy a design (1)

MMSE - 28/30

1.     CRANIAL NERVES

 1.     MOTOR SYSTEM

1.     SENSORY SYSTEM

 

 

5.   CEREBELLAR SIGNS

1.     No Titubation

2.    Truncal ataxia/gait ataxia/ stance ataxia (?)

3.     No Nystagmus

4.     Dysarthria (?)

5.     No Hypotonia

6.     No Rebound phenomenon

7.     Intention tremor present

8.     No Pendular knee jerk

9.     No Tandem Walking

10.  Coordination 

a.     Upper Limbs – Finger Nose test, Finger Finger Nose test, Drawing a circle, Putting a dot in the centre of the circle - Normal (?)

b.     Lower Limbs – Heel Knee test, Drawing a circle 

c.     No Dysdiadokokinesia

 

6.   AUTONOMIC NERVOUS SYSTEM

No Postural Hypotension, Resting tachycardia, Abnormal sweating

 

7.    SIGNS OF MENINGEAL IRRITATION

No Neck stiffness, Kernig’s sign, Brudzinski’s sign 

 

8.    EXAMINATION OF THE SPINE AND CRANIUM

No bony deformities, bruit, gibbus, tenderness, bony abnormalities, bruit

 

9.    PERIPHERAL NERVES

No Thickened nerves, Trophic ulcers, Wrist drop, Foot drop