A 50 year old gentleman with involuntary movements of the fingers of both the hands
Case presentation video :
History of Presenting illness :
The patient was apparently asymptomatic 6 months ago, when he noticed :
- Involuntary movements of the right thumb, index and middle fingers which are insidious in onset, gradually progressive, characterized by continuous, rhythmic to-and-fro movements which aggravate with emotional stress and anxiety and diminish temporarily by willed movements and sleep, as told by his family members.
- Since the last 6 days, the same involuntary movements also started appearing in his left thumb and index fingers, but are less pronounced as compared to the right side.
- Recently, the patient has also noticed involuntary movements of the jaw.
- Initially, these movements were not troublesome, but since the past few months, he hasn't been able to correct his students' college examination papers.
- On writing a sentence, the letters tend to be smaller and cramped at the end of the line. He says that his handwriting isn't what it used to be.
- He has difficulty in sitting up from a lying down position and slight difficulty in getting up from a sitting position.
- He admits to having difficulty in buttoning and unbuttoning his button cuffs on the sleeves of his shirt with his right hand, and often requires the assistance of his mother in doing so, since the past few months, whenever he has to get dressed to go to college.
(VIDEO : The patient has difficulty in buttoning his shirt sleeves with his right hand. His mother was trying to help him. So.I had to prevent her from doing so.)
- He has no history of difficulty in maintaining his posture, no history of difficulty in holding objects such as a water bottle or a newspaper, no history of difficulty in brushing his teeth or combing his hair.
- He denies having stiffness in his lower limbs, burning sensation, inability to feel hot or cold stimuli or cotton wool sensation on the floor while walking.
Past history :
- He was recently diagnosed with hypertension at our hospital, and has been taking 40 mg of Telmisartan daily.
- No history of Diabetes mellitus, Tuberculosis, Bronchial asthma or Thyroid disorders.
Personal history :
- He consumes a vegetarian diet,
- His appetite is normal, however,
- His bowel movements are irregular as he feels constipated.
- His bladder movements are regular.
- He reports an absence of morning erections and a loss of sexual desire since the past 2 months.
- He does not smoke or consume alcohol.
Family history : is not significant
Treatment history : The patient denies taking any prior treatment.
On General Physical Examination :
- The patient is conscious, coherent and cooperative, sitting comfortably on the bed.
- He is well oriented to time, place and person.
- He is moderately built and moderately nourished.
- On general examination, he has coarse and static tremors of the hands (right more than left), jaw tremors and the rate of blinking is reduced to less than 10 per minute.
- His gait has reduced arm swing
Vitals :
- Temperature = he is afebrile
- Pulse = 82 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay. The condition of the arterial wall is normal.
- Blood pressure = 190/110 mm of Hg and after standing for 3 minutes, it is 160/110 mm of Hg.
- Respiratory rate = 16 cycles per minute.
- JVP is elevated
- There is no Pallor, Icterus, Clubbing, Cyanosis, Generalized lymphadenopathy and Edema.
Nervous System Examination :
On examination of the Higher Mental Functions :
- He is conscious and well oriented to date, time, season, year, place and person.
- His speech is monotonous.
- His language is normal. His short term and long term memory (when asked to repeat 3 names of objects and when asked what he had for dinner last night)
- He is able to perform basic calculations such as subtracting 7 from 100 five times (100. 93. 86, 79, 65)
- He is able to follow a 3-stage command.
- He is also able to read and obey a written command on a piece of paper ( "Close your eyes" )
- When asked to write a sentence on a paper : The letters are smaller and cramped at the end of the line indicative of Micrographia
(VIDEO : Speech)
On examination of the Motor System :
1. Rigidity
2. Bradykinesia
3. Tremors
4. Gait and Coordination
1. Rigidity :
To elicit rigidity, I performed an activation maneuver by asking the patient to tap his hand on the thigh, while I simultaneously checked for rigidity in the wrist, elbow and the ankle.
Rigidity : Right Left
Wrist ↑↑ ↑
Elbow ↑↑ ↑
Ankle ↑↑ ↑
2. Bradykinesia :
Rapid alternating movements become slower in time.
Right Left
UPPER LIMBS : 1. Finger-thumb movement Slower Slow
2. Rapid supination and Pronation Normal Normal
LOWER LIMBS : 3. Toe Tapping Slower Slow
4. Heel Tapping Slower Slow
(VIDEOS : Test for Bradykinesia)
Bradykinesia in the right hand (which is more pronounced than that in the left hand)
Rapid supination and pronation - Diadochokinesia
Findings - The movements in the right lower limb is slower than the movements in the left lower limb.
3. Tremors :
- Coarse, resting tremors of right and left upper limbs , 3-4Hz, low amplitude.
- COGWHEEL RIGIDITY is present.
- Draw a spiral test (To rule out kinetic tremors) = Normal
- Finger-to-nose test = Normal
4. Gait and Coordination :
- Gait = Reduced arm swing
- Pull Test = Normal
- Getting up from a chair with arms crossed over opposite shoulders = Normal
- Tandem Gait = Normal
- Romberg's test = Normal
Right Left
1. Muscle Bulk Normal Normal
2. Muscle Tone
Upper limb
Shoulder Normal Normal
Elbow Hypertonia > Hypertonia
Wrist Hypertonia > Hypertonia
Lower limb Normal Normal
3. Muscle Power
Upper Limb
Proximal 5/5 5/5
Distal 5/5 5/5
Lower Limb
Proximal 4/5 4/5
Distal 5/5 5/5
4. Reflexes
Superficial reflexes
Right Left
Corneal + +
Conjunctival + -
Abdominal + -
Plantar Flexor Flexor
Deep tendon reflexes
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 2+ 3+
Ankle 1+ 2+
Clonus Absent Absent
On examination of the Cranial Nerves :
- Cranial Nerve 1 : The patient can perceive the smell of soap
- Cranial Nerve 2 : Counting fingers at 6 meters is normal
- Cranial Nerves 3, 4 and 6 : Movements of the extra-ocular muscles, Pupillary reflex and Accommodation reflex are normal. There is no ptosis or nystagmus.
- Cranial Nerve 5 : Sensory component = Ability to perceive sensation over specific areas on the face is Normal. Motor component = Jaw jerk was elicited and the muscles of mastication are normal.
- Cranial Nerve 7 : No deviation of the angle of the mouth, no loss of nasolabial folds, he is able to puff his cheeks, grin and tightly shut his eyes.
- Cranial Nerve 8 : Rinne's test = AC > BC , Weber's test is centralized.
- Cranial Nerves 9 and 10 : Uvula is centrally placed and Gag reflex is present.
- Cranial Nerve 11 : Patient is able to shrug his shoulders against resistance. Trapezius and Sternocleidomastoid are normal.
- Cranial Nerve 12 : Patient can normally move his tongue in all directions.
On examination of the Sensory System :
Right Left
1. Pain + +
2. Crude touch + +
3. Fine touch + +
4. Vibration sense
Medial malleolus 5.7s 4.6s
Patella 9s 4.3s
Elbow 4.8s 6.4s
Wrist 5s 7s
5. Proprioception Normal Normal
6. Stereognosis Normal Normal
7. Tactile localization Normal Normal
8. Two-point discrimination Normal Normal
SUMMARY :
A 50 year old gentleman presenting with a 6 months history of gradually progressive, asymmetric resting tremors with autonomic features is provisionally diagnosed with :
1. Idiopathic Parkinson's Disease Stage 2 with hypertension.
2. Multiple System Atrophy - Parkinsonian Type (MSA-P).
Treatment :
1. Tab. Syndopa Plus 125 mg QID
2. Tab. Syndopa 125 mg CR OD
3. Tab. Telma 40 mg OD
4. 4th hourly BP/PR/Temp monitoring
ACTIVE LEARNING DISCUSSION :
[3/5, 10:23 PM] MBBS UG Student 1: Sir, today, when you asked me about the speech, I said that it appeared normal because he was able to repeat the words "Hippopotamus" and "British Constitution" fairly fluently.
[3/5, 10:24 PM] Post-residency PG 1: Yes but that would have been impaired only if he had spastic dysarthria (British constitution) and scanning speech (cerebellar lesion)
[3/5, 10:25 PM] MBBS UG Student 1 : How can we test for speech in this case, sir?
[3/5, 11:14 PM] Post-residency PG 1: Parkinson's disease has two main symptoms, dysprosody and dysphonia.
Measures such as cepstral separation difference (CSD) features to quantify dysphonia and dysprosody accurately distinguish the severity of speech impairment.
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Contributions -
- Shwetha Jadhav
- Aditya sir
- Sravya Kandala ma'am
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