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Neurology Clerk’s Hour

Aileen Concepcion M. Agustin


Medical Clerk Rotator – Department of Neurosciences
Mariano Marcos Memorial Hospital & Medical Center
Outline
• Objectives
• Clinical History and Physical Examination
• Approach to a Patient with Movement Disorders
• Differentials, Diagnostics and Diagnosis
• Case Discussion and Conclusion
Objectives
• Present a case manifesting with dystonia
• Review the approach to a patient with movement
disorder
• Discuss the focal dystonia, its pathophysiology and
manifestations
• Describe the management of dystonia from the
viewpoint of a general physician
Clinical History and
Physical Examination
General data
• MD
• 40 year-old
• Filipino male
• Single
• Roman Catholic
Chief complaint
• Intermittent neck spasm
History of present illness
• 1 year PTC (+) episodes of muscle contraction of
neck muscles, shoulder shrugging, lasting 1 minute,
interval of few minutes, (+) stiffness, limited head
mobility with tendency for his head to turn to the
right and tilt to the left, aware when spasms occur,
no LOC, no upward rolling of eyeballs, no salivation,
no numbness or tingling sensation, no dizziness, no
headache, no nausea or vomiting, no history of
trauma.
History of present illness
• Interval history revealed development of increasing neck
discomfort, left shoulder pain and an irregular tremor of the
head. Abnormal head positioning, pain, and tremor are
partially relieved if he gently touches his left cheek with his
hand.
• 9 months PTC, increased frequency and duration of muscle
contractions, worsens when patient is stressed, slightly
decreased during sleep, still no consult done.
• 1 week PTC, symptoms now interfering with ADLs, consult at
MHO with impression of muscle spasm and given Vitamin B
complex tablet OD, no relief or improvement of symptoms.
• Patient was referred to Department of Neurology for further
evaluation, hence, OPD consult.
Past medical history
• + bullet trauma to nape area, year unrecalled
• No HTN
• No DM
• No asthma
• No recent trauma or fall
• No history surgery
• No birth trauma
• No seizures
• No previous hospitalizations
• Medications: Vitamin B complex tab OD
Family history
• + HTN – uncle
• + Stroke – uncle
• No DM
• No asthma
• No cancer
• No seizures
• No neurologic or psychiatric disease
Personal and social history
• Manual laborer
• Elementary graduate
• Non smoker
• Non alcoholic drinker
• No allergies
• No illicit drug use
• Fond of coffee, 3 cups/day
Review of systems
• General: (-) weight loss (-) fever (-) weakness (-) easy
fatigability
• Skin: (-) rashes (-) pruritus (-) easy bruising (-) hair loss
(-) jaundice (-) cyanosis (-) dryness
• Head: (-) headache (-) head injury (-) light headedness
• Eyes: (-) eye pain (-) dryness (-) inflammation (-)
discharge (-) redness (-) blurred vision (-) double vision
• Ears: (-) hearing loss (-) tinnitus (-) earache
• Nose: (-) colds (-) epistaxis (-) sinus tenderness
Review of systems
• Mouth and Throat: (-) oral ulcers (-) non-healing sores
(-) dysphagia (-) odynophagia (-) hoarseness (-) gum
bleeding (-) neck mass (-) swollen lymph nodes (+)
stiffness (+) pain
• Respiratory: (-) cough (-) sputum (-) dyspnea (-)
hemoptysis
• Chest: (-) chest pain (-) tightness (-) palpitations (-)
orthopnea (-) paroxysmal nocturnal dyspnea
• Gastrointestinal: (-) abdominal pain (-) nausea (-)
vomiting (-) heartburn (-) bloatedness (-) diarrhea (-)
melena (-) constipation
• Urinary: (-) dysuria (-) increased frequency (-) urgency (-
) flank pain (-) hematuria (-) incontinence
Review of systems
• Peripheral vascular: (-) claudication (-) leg cramps (-)
edema (-) varicose veins (-) discoloration
• Musculoskeletal: (-) redness (-) trauma (-) heel or back
pain (-) numbness or tingling sensation (-) myalgia (-)
gross deformity
• Neurologic: (-) seizures (-) numbness (-) dizziness
(-) loss of consciousness (+) tremors
• Endocrine: (-) heat or cold intolerance (-) polyuria (-)
polyphagia (-) polydypsia
• Psychiatric: (+) stress (-) nervousness (-) depression (-)
memory loss
Physical examination
• General Survey:
• Awake, coherent, cooperative, answers questions with 1 to 2
words; not in cardiorespiratory distress; mesomorph;
ambulatory, in a stooped posture, rises and walks slowly with
short steps, lacks any arm swing
• Vital signs:
• BP: 130/70 mmHg
• PR: 82beats/min
• RR: 20 breathes/min
• Temp: 36.2C
• SpO2: 97%
• Anthropometrics:
• Wt: 48 kg Ht: 150 cm
• BMI: 21.33 kg/m2
Physical examination
• Skin:
• No male pattern baldness. Brown complexion. no active
dermatologic lesions. No pallor, jaundice, cyanosis. Afebrile.
Good skin turgor.
• HEENT:
• No lesions on scalp, no contusions, no asymmetry
• Anicteric sclera, pink palpebral conjunctiva, (-) dryness (-)
inflammation (-) redness (+) ROR OU.
• No ear pain, (-) swelling (-) discharge (-) tragal tenderness
• Nasal mucosa pink (-) discharge. Septum midline, (-) sinus
tenderness
• Pink lips. Moist oral mucosa. (-) mouth ulcers, no
tonsillopharyngeal congestion.
• Neck tense, no cervical lymphadenopathy, no neck vein
engorgement. No bruits.
Physical examination
• Chest and Lungs:
• Symmetric with equal chest expansion, (-) retractions (-)
tenderness. Clear breath sounds, (-) crackles (-) wheezes
• Cardiovascular:
• Adynamic precordium, (-) heaves, (-) thrills. PMI at 5th ICS
LMCL, brisk and tapping. Normal rate regular rhythm. Distinct
S1 and S2. (-) S3 or S4 (-) murmurs
• Abdomen:
• Flabby. Normoactive bowel sounds. (-) bruits. Tympanitic.
Soft abdomen. (-) tenderness (-) masses. (-) CVA tenderness.
• Extremities:
• (+) extension deformity left elbow. Pink nail beds. No clubbing
or cyanosis. Full equal pulses. Calves are supple, non-tender.
No atrophy. No edema. No warmth. Capillary refill time <2s.
Neurologic examination
• GCS:
• 15/15 (E4V5M6)
• Cerebral:
• Alert, awake, oriented to person. Right handed.
• Cerebellar:
• (+) tremors (-) nystagmus (-) dysmetria (-) overshooting
• Cranial nerves:
• II – PERRL (3 mm to 2 mm) OU. (+) Pupillary reflex, (-) RAPD OU.
• III, IV, VI – EOMs full ROM and equal without ptosis. Visual fields full.
• V – Intact and equal sensation. (+) Corneal reflexes. Masticator muscles
5/5
• VII – (-) facial asymmetry. Facial muscles 5/5.
• VIII – Gross hearing intact.
Neurologic examination
• Cranial nerves:
• IX and X – (+) gag reflex. (-) dysarthria or dysphagia.
• XI – increased tone of left SCM and Trapezius muscles with head
turning to the right, + hypertrophy
• XII – Tongue midline, (-) deviation or fasciculations.
• Motor:
• Increased tone and hypertrophy of left neck muscles; occasional rigidity
both arms; normal muscle bulk and tone on the other groups. Motor
strength on major muscle groups 5/5.
• Sensory:
• Intact and equal sensation to crude and light touch and pain.
• Reflexes:
• 3+ bilateral knee reflex, others 2+. No Babinski or clonus.
• Miscellaneous:
• No nuchal rigidity.
Salient features
• Worse with stress
• Decreased during sleep
Subjective
• 40 y/o Filipino male • Impaired ADLs
• Intermittent neck spasm • No LOC
• 1 year duration • No numbness or tingling
• 1 minute every few minutes • No headache
• Stiffness
• Bullet trauma to nape area
• Limited head mobility
• Head turn to right
• No birth trauma
• Tilt to the left • No family history of neurologic
diseases
• Left shoulder pain
• Irregular tremor of head • Manual labourer
• Progressive symptoms • No illicit drug use
• Partial relief with sensory tricks • No vices
Salient features

Objective • XI – increased tone of left


• stooped posture, rises and SCM and Trapezius muscles
walks slowly with short with head turning to the
steps, lacks any arm swing right, + hypertrophy
• Tense neck area • Increased tone and
hypertrophy of left neck
• (+) extension deformity left muscles; occasional rigidity
elbow both arms
• (+) tremors • 3+ bilateral knee reflex
• Sensory intact
Present working impression
• Idiopathic cervical dystonia versus X-linked
Dystonia-Parkinsonism
Approach to a Patient
with Movement
Disorders
Differential diagnosis
Diagnostics
Plan
• Start Carbidopa 25mg/Levodopa 100mg tab BID
• Pregabalin 50mg tab OD HS
• Refer to PT and Rehab
• Follow up
Case discussion
Idiopathic cervical dystonia?
Epidemiology
Clinical Characteristics
Pathophysiology
Diagnostics
Management
Prognosis
Monitoring
Patient Instructions
When to refer
• For EMG referral
• When adjusting doses and minimizing side effects
Conclusion