60 /Female with slowness of movement/ Long case

60 /Female with slowness of movement/ Long case

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Chief compliants

1) Slowness of movements since 1 year .

2) Involuntary movements of the Left upper limb.

3) Slowness in speech since 1 year.


History of present illness

60 year old female,who is a mother of 3 children (  1 son and 2 daughters ), labour by occupation ( goes to agriculture field ) was apparently asymptomatic 1 year back, then developed Slowness of movements which was insidious onset, gradually progressive not associated with any weakness associated with difficulty in initiation of movement and difficulty in day to day activities .The difficulty was in such a way that she could not even comb the hair, mix the food and bathing.
History Involuntary movements of the left upper limb since 1 year , occuring at rest ,aggravated by emotional stress and disappeared during sleep and movement.

History of associated postural changes .

No History of sensory disturbances 

No History of anosmia.

History of sleep disturbances- present 

No History of Genito urinary and Gastro intestinal disturbances.

No History of Dysphagia 

No History of fever , convulsions and coma

No History of head injury

No History of yellowish discoloration of eyes

No History of usage of any antipsychotic drugs.

Family History: 

No Significant family History

Personal history: 

Mixed diet 
Normal bowel and bladder
Sleep: 

Past history

No history of similar complaints in the past .
No history of Diabetes, Hypertension, Cerebrovascular disease, Cardiovascular disease .

General Examination: 

Patient is conscious and Co operative.

Facies : 

Infrequent blink with Starring look.
Loss of facial expression.

No pallor, icterus, Cyanosis, clubbing,lymphadenopathy, edema

Pulse : 

BP: supine - 110/70mmhg 
       PR: 80bpm
       Standing - 100/70 mmhg.
       PR: 90 bpm

Posture : stopped posture.

Neurological examination: 

1. HIGHER MENTAL FUNCTIONS:
a. Consciousness-   Normal
b. Orientation to time, place and person- present.
c. Speech and language -slow speech.
d. Memory -Normal
e. Delusions, hallucinations- No
f. Emotional lability
g. MMSE score
I. Orientation
1.date, day, mönth, season, year -4
2. floor, hospital. District, state, country- (5) 
II. Registration
Name three objects taking one second for each obiect. Ask him to repeat the same
Repeat till he remembers (3) 
III. Attention and Calculation 
Serial 7's 5 times - 4 points.
IV. Recall
Recall the three objects (3) 
V. Language
I. Name 2 obiects (2) 
2. Repeat a sentence (1) 
3. Follow a 3 stage command (3)
4. Reading "close your eyes"- Not done.
5. Writing a sentence - Cannot write.
6. Copy a design (1)

TOTAL SCORE- 26/30

2] CRANIAL NERVES.                               
I) Sense of smell      - Normal on both sides.                               
II) On Right side - No perception of light 
On left side - Visual acuity, colour vision - Normal.                                      
III,IV,VI)
i) Extra-ocular movements  - Normal in both eyes .                    
ii) Pupil - Size - 2-3 mm in both eyes.                                          
ili) Direct Light Reflex - Sluggish in right eye 
     Constriction of pupil- left eye.                      
iv) Consensual Light Reflex- Absent in left eye.                      
v) Accommodation Reflex - Absent in right eye,                          
vi) Ptosis    - absent                                              vil) Nystagmus    - absent                 
V) 
i) Sensory -over face and buccal mucosa -presen 
il) Motor - masseter, temporalis, pterygoids- normal 
iii) Reflex a.Corneal Reflex  - present in both eyes.                              
b. Conjunctival Reflex  - present in both eyes.  C.Jaw jerk - absent                                                VII)
i) Motor - intact on both sides                            il) Sensory -
Taste of anterior 2/3rds of
tongue- present.
Sensation over tragus                                
iii) Reflex -
Corneal- present                                                    Conjunctival- present.                                          
8)
i) Rinnes Test - AC more than BC                        ii) Webers Test- unable to perceive the vibrations when tuning fork - kept on fore head.
IX,X)
i) Uvula, Palatal arches, and movements- Normal 
¡¡)Gag reflex - Present                                        
iii) Palatal reflex- Present                       
XI)
i) trapezius- able to perform .                              ¡¡)sternocleidomastoid -slight difficulty in turning                
XII)
¡)Tone-Normal                                                 
¡¡)wasting- No                                                 
iii) Fibrillation-No                                                   iv) Movements - normal.

3] Motor system 
I- BULK
a. Inspection   - Normal                                           
b. Palpation     - Normal                                           
c. Measurements     
Upper limb- MAC -30 cm on both sides.
Lower limb-MLC -  31cm on both sides                        
II - TONE
a.Upper limbs- Fluctuant rigidity in upper limbs - Cog wheeling type .
b. Lower limbs- rigidity experienced throughout movement - Lead pipe type.
III - POWER
a. Neck muscles- 5/5 
b. Upper limbs
i)Shoulder
Flexion-Extension-5/5
Lateral Rotation-Medial Rotation-5/5
Abduction -Adduction-5/5
ii)Elbow
Flexion-Extension-5/5
iii)Wrist
Dorsi flexion-Palmar flexion-5/5
Abduction-Adduction-5/5
Pronation-Supination-5/5
iv)small muscles of hand-5/5
V)Hand grip- Normal.

с.Lower limbs
i)Hip
Flexion-Extension-5/5
Abduction-Adduction-5/5
Lateral Rotation-Medial Rotation-5/5
ii)Knee
Flexion-Extension-5/5
iii)Ankle-
Dorsi flexion-Plantar flexion-5/5
Inversion-Eversion-5/5

IV -REFLEXES
A. SUPERFICIAL REFLEXES( Both sides ) 
1. Corneal- Present 
2. Conjunctival- Present.
4. Palatal Reflex-present 
5. Abdominal Reflex-present 
5. Plantar Reflex- Negative.

B. DEEP TENDON REFLEXES( Both sides ) 
1. Jaw jerk- Absent 
4. Biceps jerk- +2 
5. Triceps jerk-+2
6. Supinator jerk-+2
7. Finger flexion reflex- no response.
8. Knee jerk-+2
9. Ankle jerk-+2
10. Clonus- Absent 

VI GAIT- Video 


VIl - INVOLUNTARY MOVEMENTS- Absent 
A - Athetosis, Asterexis
B- Ballismus
C - Chorea
D- Dystonia
E - Essential tremors
F -Fasciculations
M - Myoclonus

4]SENSORY SYSTEM
TEST
I - SPINOTHALAMIC( Both sides )
1. Crude touch- Normal 
2. Pain- Normal 
3. Temperature- Normal 

II - POSTERIOR COLUMN
1. Fine touch- Normal 
2. Vibration- Normal 
3. Proprioception - Normal
4. Romberg's sign- negative

III - CORTICAL( both sides ) 

1. Tactile localisation- present
2. Graphaesthesia- Present 
3. Stereognosis- present 

5]CEREBELLAR SIGNS
 Coordination( on both sides ) 
a. Upper Limbs - Finger Nose test, Finger Finger Nose test, Drawing a circle,
Putting a dot in the centre of the circle ~ Present 
b. Lower Limbs - Heel Knee test
c. Dysdiadokokinesia- Absent

6. AUTONOMIC NERVOUS SYSTEM
Postural Hypotension
Resting tachycardia
Abnormal sweating

7. SIGNS OF MENINGEAL IRRITATION
Neck stiffiness- Absent 
Kemig's sign-Absent 
Brudzinski's sign-Absent 

Examination of other systems: 

 CARDIOVASCULAR SYSTEM:
JVP- Not raised ,Apex normally placed, no Palpable P2, Heart sounds - normal, No thrills/murmurs

RESPIRATORY SYSTEM:
Chest symmetrical, No paradoxical movements, Normal vesicular breath sounds heard,
No abnormal/added sound

ABDOMEN:
Abdomen is soft, No organomegaly, No ascites.

Test for extensor digitorum brevis
Rinnes test

Tibialais posterior.

Ilio psoas

Interossei muscle testing

Lumbricals

Adductor pollicis 

Testing for pain:



DIAGNOSIS
INVESTIGATIONS: 

RBS- 91mg/dl
Blood urea- 28mg/dl
Serum creatinine - 0.7mg/dl

CUE
Colour: pale yellow
Appearance: Clear
Albumin NIL
Sugar NIL
Bile salts and pigments NIL
Pus cells: 2-3
Epithelial cells: 2-3
RBC NIL
Crystals, casts NIL
Amorphous deposits NIL

HEMOGRAM
HB: 13.2
TLC: 7700
N/L/E/M: 53/33/4/10
PCV: 40.3
MCV: 82.3
MCB: 27.1
MCHC: 32.8
RBC: 4.87
PLT: 3.5

LFT
TB: 1
DB: 0.2
AST: 17
ALT: 9
ALP: 148
TP: 7.4
ALBUMIN: 4.0
A/G: 1.2

HIV- negative
HBsAg- negative
HCV- negative

ECG: 

CXR- PA 

TREATMENT: 

1) Tab Syndopa ( levodopa 100mg+ Carbudopa 25 mg) PO/OD.

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