1. KANNUR CLINICAL CLUB CASE PRESENTATION TWO CASES OF MOVEMENT DISORDERS MUHAMMED BUJAIR MBBS-06

2. CASE - 1

3. NAME : MARIYAM AGE : 75 SEX : F OCCUPATION : HOUSE WIFE ADDRESS : ANJARAKANDY

4. PRESENTING COMPLAINTS VIOLENT MOVEMENTS OF LEFT UPPER AND LOWER LIMBS- 4 DAYS -video-

5. HISTORY OF PRESENTING ILLNESS Mode of onset-sudden,4 days back Started first in the upper limb- after 1 day lower limb also involved- with flinging movements Progressive in nature No associated muscle wasting/weakness, Power-normal

6. No h/o of convulsion & twitching of muscles No diurnal variation Not associated with pain over muscles No loss of sense of temperature/pain Patient is disoriented, conscious & memory decreased

7. PAST HISTORY No h/o of previous similar episodes She was a hypertensive patient 10yr back and she was under medication for 6 yrs Stopped when it became normal At present she is not taking medication H/o headache and vertigo during the period of hypertension

8. H/o deviation of angle of mouth to left side- 4yr back Cured under medication No h/o of DM/TB/IHD/Bronchial asthma No h/o of trauma, fits and convulsions

9. PERSONAL HISTORY Sleep, apettite,bowel and bladder-normal No habit of smoking, consuming alcohol and chewing No addictions

10. FAMILY HISTORY Nothing significant TREATMENT HISTORY Taken treatment for hypertension-10yrs back-for a period of 6 yrs-then stopped when it became normal

11. EXAMINATION GENERAL EXAMINATION Disoriented, Conscious, and co-operative Poorly built and nourished Pallor is present No icterus, clubbing, cyanosis, lymphadenopathy, edema

12. VITALS Pulse-78 bpm regular rhythm normal character normal volume normal vessel wall no radio femoral delay no carotid bruit

13. Respiration 18 cycles per minute regular rhythm, normal character and depth Blood pressure 126/80 mmHg right upper limb supine position Afebrile

14. CNS EXAMINATION Higher function Disoriented, Conscious and co-operative Memory-decreased Difficulty in speech Cranial nerves All cranial nerves are normal

15. Motor system No muscle wasting, hypertrophy/weakness TONE: decreased(hypotonia)on left upper and lower limbs compared to right Rigidity(cog wheel/lead pipe) absent CLONUS: Ankle/patellar clonus-absent POWER: normal REFLEXES:Both superficial and deep tendon reflexes are normal on both sides Abnormal, involuntary, violent movements of left upper and lower limbs are present

16. Sensory system No sensory loss Touch,pain and temperature are normal on Rt and Lt side Posture and gait Unsteady gait associated with involuntary movements of both limbs in left side No kyphoscoliosis/lordosis

17. EXTRA PYRAMIDAL SYSTEM Akinesia or rigidity-absent Abnormal involuntary movements on both limbs on left side PERIPHERAL NERVOUS SYTEM: Normal Signs of meningeal irritation: Absent Examination of skull and spine: Normal

18. Investigation: 1.Blood Hb :10mg/dl RBS :80mg/dl Urea :34mg/dl S.Creatine :1.7mg/dl TLC :8500 cells/Cu mm DLC : Neutrophil-63% Eosinophil-2% Basophil-0% Monocyte-1% Lymphocyte-34% ESR 1 st hour :10 mmHg

19. 2.CT SCAN Impression: An infarct in subthalamic nucleus

20. CASE - 2

21. NAME : KUNCHIRAMAN AGE : 80 SEX : M OCCUPATION : MANUAL LABOURER ADRESS : PARAMMAL IRITTY

22. PRESENTING COMPLAINTS 1. Involuntary movements of left upper and lower limbs-2 wk 2. Speech difficulty-2 wk -video-

23. HISTORY OF PRESENT ILLNESS Started following an episode of stroke before 4 week-with sudden weakness on left upper and lower limb After 2 wk developed abnormal involuntary movements involving left side of body Associated with h/o speech difficulty-2 weak No h/o head ache/head injury No h/o of seizure attack No associated muscle wasting, sensory loss or pain over muscle

24. PAST HISTORY Patient is a known diabetic No h/o HTN/TB/IHD PERSONAL HISTORY Sleep, appetite, bowel, bladder-Normal No addictions FAMILY HISTORY Nothing significant

25. EXAMINATION GENERAL EXAMINATION On examination patient is conscious, co- operative, moderately built and nourished. No pallor, icterus, clubbing, cyanosis, lymphadenopathy or oedema Vitals are normal

26. CNS EXAMINATION On examination, involuntary violent and arrhythmic movements of Lt upper limb and lower limb Power : Rt Lt UL 4+ 4+ LL 4+ 4+ Reflex : Plantar-extensor

27. Investigation : 1.Blood: Hb :12 mg/dl RBS :105 mg/dl Urea :34 mg/dl S.Creatine :1.7 mg/dl TLC :8500 cells/Cu mm DLC & ESR : Normal 2.CT SCAN An infarct in subthalamic nucleus on right side

28. DIAGNOSIS HEMI BALLISMUS- Secondary to stroke Treatment given : Oleanzepine Condition at discharge Results awaited in the female Completely cured in the male

29. BALLISM Is a form of forcefull,flinging,high-amplitude, coarse choreic movements of the proximal parts of limb The involuntary movement usually affect only one side of the body-which is termed as hemiballism Occures due to a lesion in the contralateral subthalamic nucleus or its connections or of multiple small infarcts in the contralateral striatum

30. AETIOLOGY 1.Stroke-is the most common cause (ischaemic and haemorrhagic shock) 2.Tumours,Abcesses,encephalitis,vasculitis 3.Less common causes are Arterio-venous malformation Hyper osmotic hyper glycemia Multiple sclerosis SLE and tuberculous sclerosis Basal ganglia calcification Non-ketotic hyper glycemia

31. TREATMENT 1)Dopamine-receptor blocking drugs- Haloperidol,chlorpromazine,pimozide and atypical neuroleptics-have been used most frequently 2)Dopamine depleting drugs-reserpine, tetrabenazine Tardive dyskinesia-induced by chronic anti dopaminergic treatment 3)Other drugs-sodium valproate,clonazepam 4)Ventrolateral thalamotomy &other steriotactic surgeries

32. THANK YOU