MOVEMENT DISORDER FULL chbg hypertension hyperglycemia.pptx

Good morning everyone

1. AN INTERESTING CASE OF MOVEMENT DISORDER DR NEETHU JR2 SECOND UNIT

2. A 65 yr old female resident of Aathoor who is a house wife came with chief c/o altered sensorium x 1 day c/o involuntary movements of left upper limb x1day

3. History of presenting illness Patient was apparently normal 1 day back when she developed altered sensorium which was insidious in onset ,progressive in nature. c/o involuntary , irregular,sudden jerky movements of left upper limb which was insidious in onset gradually progressive ,continuous ,aggravated when she tried to reach for objects and while trying to hold them,which disappeared on sleep. No h/o headache/ fever No h/o nausea/ vomiting/photophobia No h/o trauma /fall No h/o weakness of limbs No h/o slurring of speech No h/o gait disturbances/ behavioral changes

4. No h/O Loss of vision,smell and taste No h/O Hearing impairment/Vertigo No h/O Hoarseness of voice,dysphagia,nasal regurgitation No h/O difficulty in neck movements No h/O Difficulty in chewing/swallowing No h/O loss of sensations over body No h/O palpitations,perspiration syncopal attacks,postural giddiness ,skin dryness,bowel and bladder disturbances No h/O dysuria/reduced urine output No h/O yellowish discolouration of urine,abdominal distension ,pedal edema

5. No h/ o chest pain , breathlessness NO h / o Cough with expectorations No h/ o any bleeding manifestations No h/ o Abdominal pain, loosestools , vomiting No h/ o Loss of weight/ appetite NO h/o joint pain,hair loss or skin lesions No h/o stoopped posture No h/o diminished arm swinging

6. PAST HISTORY No h/o similar complaints in the past K/C/O T2DM x10 yrs on irregular treatment K/C/O Systemic hypertension x 6 yrs on irregular treatment

7. PERSONAL HISTORY Mixed diet Normal bowel and bladder habits Normal sleep and appetite No addictions

8. MENUSTRAL AND OBSTETRIC HISTORY P2L2 Attained menopause at 49 yrs of age

9. GENERAL EXAMINATION Drowsy Arousable Afebrile Dehydration ++ Involuntary jerky movements of left upper limb + No pallor/icterus /cyanosis/clubbing / lymphadenopathy/pedal edema No peripheral nerve thickening No neurocutaneous markers

10. vitals BP :130/80 mmHg measuted in all four limbs in supine position PR:88/min ,regular rhythm,normal volume ,normal character,no radioradial or radiofemoral delay,no vessel wall thickening,peripheral pulses felt equally SPO2 :99%in room air Temp :98.6 F CBG : High

11. Systemic examination CVS :S1S2+,No murmur RS: BLAE+,NVBS, No added sounds P/A :Soft ,BS+ Non tender ,not warm No palpable organomegaly

12. CNS Drowsy Arousable Not oriented to time,place,person Speech – could not be assessed Memory – couldnot be assessed No delusions or hallucinations

13. At the time of admission patient was drowsy ,disoriented. Her sensorium improved by next day afternoon and then CNS examination done is as follows

14. Cranial nerve examination

15. -absent

16. SPINIMOTOR SYSTEM Bulk Right Left Upper limb Arm 22 22 Forearm 18 18 Lowerlimb Thigh 35 35 Leg 24 24 Tone Right Left Upper limb Normal Normal Lower limb Normal Normal

17. Upper limb Right Left SHOULDER Flexion 5 5 Extension 5 5 Abduction 5 5 Adduction 5 5 ELBOW Flexion 5 5 Extension 5 5 WRIST Flexion,extension 5 5 Supination pronation 5 5 Lower limb Right Left HIP Flexion,extension 5 5 Abduction, adduction 5 5 Medial rotation Lateral rotation 5 5 KNEE Flexion 5 5 Extension 5 5 ANKLE Dorsiflexion Plantar flexion 5 5 Inversion Eversion 5 5

18. Superficial reflexes deep tendon reflexes Right Left Corneal reflex Present Present Conjunctival reflex Present Present Abdominal reflex Present Present Crematorium reflex Present Present Anal reflex Present Present Plantar Flexor Flexor Right Left Biceps ++ ++ Triceps ++ ++ Supinator ++ ++ Knee jerk ++ ++ Ankle jerk ++ ++

19. SENSORY SYSTEM Right Left Fine touch Normal Normal Crude touch Normal Normal Pressure Normal Normal Pain Normal Normal Temperature Normal Normal Vibration Normal Normal Proprioception Normal Normal Tactile discrimination Stereognosis graphaesthesia Normal Normal

20. CEREBELLAR FUNCTION TESTS Coordination test Right Left FNT Normal Normal FNFT Normal Normal Dysdiadochokinesia Normal Normal Heel knee test Normal Normal INTENTIONAL TREMORS PRESENT INVOLUNTARY MOVEMENTS OF LEFT UPPER LIMB PRESENT MYERSON SIGN NEGATIVE NO COGWHEEL RIGIDITY NO PRIMITIVE REFLEXES No ATAXIA/NYSTAGMUS NO BOWEL AND BLADDER INVOLVEMENT NO TITUBATION NO GAIT ABNORMALITIES No signs of meningeal irritation Spine and cranium normal

21. investigations Hb :13.1 T protein : 5.3 T4:1.04 TC : 9400 Alb :3.3 TSH :1.16 P/L/E :68/25/7 Glb :2.3 URE PCV :40 Urea : 16 Sugar+++ PLT: 1.9L Creat :1.0 Alb : Nil TB :0.4 Sodium :140 pus cells :6-8 DB :0.1 Potassium :3.9 epi cells :2-3 IB :0.3 RBS:440 acetone :negative OT/PT :16/12 HbA1c :10.8 ALP :131 S Ca :10.7

22. CRP -6 ANA –negative ASO –negative VCTC –Non reactive VDRL –Negative HbsAg –Negative AntiHCV -Negative

23. 1706- MP- Negative 1707- MF -Negative 1708 –Urine C/S –Candida species growth 1715 – Blood C/S – No growth in culture 7624 – Dengue Igm –Negative 7625- Lepto -Negative 7626 –scrub -Negative 7627- widal –Negative

24. ecg

25. ECHO EF :60% N LVEF

26. Usg abdomen and pelvis Grade I Fatty liver No free fluid in abdomen

27. Ct brain B/l basal ganglia calcification

28. MRI BRAIN

29. Diffuse cerebral atrophy Multiple small T2W/FLAIR high signal intensity lesions , not showing diffuse restriction seen in the centrum semiovale,corona radiata and periventricular white matter suggestive of chronic small vessel ischemic demyeilination changes. Patchy areas of T1 and T2 hyperintensities seen in the bilateral basal ganglia –possibility of metabolic insult should be ruled out.

30. NEURO OPINION Imp : ?Parkinsonism Added T THP,T Syndopa,Inj Thiamine

31. THANK U