CASE

PRESENTATION
Dr Pallabi Dash
3rd Year Post Graduate
Name: bigyan Jena

Age : 30 years
Sex : male
CHIEF COMPLAINT
Abnormal movements in hands and legs - 8 years
HISTORY OF PRESENT ILLNESS
Patient was apparently alright 8 years back. To start with he
developed gradual onset involuntary movements in right hand
followed by right leg followed by left hand over a period of 6 months.
The involuntary movements were to and fro, initially limited to hands
and feet only and were present for few hours throughout day and
disappeared during sleep. These were associated with slowness of
activities, abnormal sweating. But the patient could do his daily
activities despite these abnormal movements.

These movements gradually progressed and persisted throughout the

day and limited his daily activities for which he sought treatment. The
patient has subsequently been diagnosed as a case of Parkinson’s
disease.

However, the tremors were poorly controlled with medication and

became increasingly disabling and has been associated with abnormal
posturing and abnormal cries for one year.
HISTORY OF PAST ILLNESS

Patient is a known case of intellectual disability

 FAMILY HISTORY
Nothing suggestive.

PERSONAL HISTORY
Socioeconomic Status- lower middle
Education- class 5.
No addiction
Both veg and non veg diet
TREATMENT HISTORY
Has previously been treated as a case of Parkinson’s
disease with levodopa carbidopa, pramipexole and
trihexyphenydil.
GENERAL EXAMINATION
Patient is conscious, cooperative
Body built : average
Length = 175 cm
There is no pallor, icterus, cyanosis, clubbing, pedal edema
or enlarged lymph nodes.
JVP is not raised.
No thyroid enlargement
Skin, Hair conditions are normal
 Pulse: 84/min, regular, normal in volume & character, no
radio-femoral delay, arterial wall just palpable, all peripheral
pulses are well felt

Blood Pressure: 116/76 mm of Hg Right arm supine position

124/82 mm of hg right leg supine position

Respiratory rate: 14 /min, abdomino thoracic.

Temperature - 98.6° F oral

EXAMINATION OF NERVOUS
SYSTEM
HIGHER FUNCTIONS OF CNS
Patient is conscious, cooperative, well oriented to time,
place and person
Has decreased word frequency and abnormal pronunciation
in his speech
Intact memory, insight, judgement and abstract thought
EXAMINATION OF THE CRANIAL NERVES

1.Olfactory nerve :
Sense of smell in both the nostrils intact.

2.Optic:-
Visual acuity- Both eye normal
Colour Vision- Both eye normal
Field of vision- Both eye normal
Fundoscopy- Normal
3.Oculomotor, Trochlear, Abducens Nerve:

No Ptosis,
Movement of eyeball normal in all directions.
Pupils: size and shape normal and equal in both eyes.
Light reflex: direct and consensual light reflex present in
both eyes
Accommodation reflex present.
Nystagmus present
4. Trigeminal Nerve:
No weakness of muscle of mastication
Sensation over face normal
Corneal reflex present in both the eyes
Jaw jerk absent

5. Facial nerve
No weakness in muscles of facial expression.
Taste sensation in anterior 2/3rd of the tongue intact.
6. Vestibulocochlear Nerve :
Rinne’s test: AC>BC
Weber’s test: not lateralized.
7. Glossopharyngeal & Vagus Nerve:
Uvula central.
Palatal movement- bilaterally normal.
Gag reflex- present.
8. Accessory Nerve :
No weakness of Sternocleidomastoid and Trapezius muscle.

9. Hypoglossal Nerve :

Movements of tongue muscle normal, no deviation.

No atrophy, no fasciculation
MOTOR SYSTEM EXAMINATION
1.BULK: no wasting of muscles
RIGHT LEFT

ARM 32cm
32cm
FOREARM 23cm 23cm

THIGH 45cm 44cm

LEG 37cm 36.5cm

2.TONE
Around the joints of upper limb: normal
Lower limb: hypertonic
3. POWER:

JOINT MUSCLE GROUPS RIGHT LEFT

SHOULDER ABDUCTORS 4/5
4/5

ADDUCTORS 4/5 4/5

FLEXORS 4/5
5/5

EXTENSORS
5/5 5/5

ELBOW FLEXOR
5/5 5/5

EXTERSORS
5/5 5/5

WRIST EXTENSORS
5/5 5/5

FLEXORS
5/5 5/5

HAND GRIP NORMAL NORMAL

JOINT MUSCLE GROUPS RIGHT LEFT
HIP ABDUCTORS 2/5 3/5
ADDUCTORS
2/5 3/5

FLRXORS
2/5 3/5

EXTENSORS
2/5 3/5

KNEE FLEXOR 2/5

3/5

EXTERSORS
2/5 3/5

ANKLE DORSIFLEXORS
2/5 3/5

PLANTAR FLEXORS
2/5 3/5
4) REFLEXESDEEP TENDON REFLEXES

Right Left

Upper Limb Biceps Normal Normal

Triceps Normal Normal

Supinator Normal Normal

Lower Limb Knee Exaggerated Exaggerated

Ankle Clonus Clonus

SUPERFICIAL REFLEXES :
1.

1.

1. Abdominal reflex : Absent

2. Plantar : B/L non responsive
SENSORY EXAMINATION
Modality of sensation could not be tested
5. CO-ORDINATION : intensional tremor

6. GAIT : could not be tested

7. INVOLUNTARY MOVEMENT : Absent

8.CEREBELLAR SIGNS: nystagmus, intentional tremor

AUTONOMIC NERVOUS SYSTEM

Bowel and bladder sensation and control-normal

No postural
SKULL ANDhypotension.
SPINE: normal

MENINGEAL SIGNS: Absent

PERIPHERAL NERVE : not thickened

EXAMINATION OF CARDIOVASCULAR
SYSTEM

INSPECTION :-
Precordium normal in shape
No dilated veins and visible scars seen
Apical impulse not visible
No other pulsation seen.

PALPATION:-
Apical impulse -present in left 5th ICS , on Mid
clavicular line, normal in character.
Pulmonary area : P2 not palpable.
No thrill.
PERCUSSION:-
2nd left intercostal space - resonant
Cardiac dullness starts from left 3rd ICS & does not
extend beyond the apex.
AUSCULTATION:-
1) MITRAL AREA:

1st heart sound normal

No added sound.
No murmur
2) PULMONARY AREA :
Pulmonary Component of 2nd Heart Sound Normal
No Split
No added sound
3) AORTIC AREA :
Aortic component of 2nd heart sound normal
No added sound
No murmur

4) TRICUSPID AREA:
1st heart sound heard normal
No murmur
EXAMINATION OF RESPIRATORY SYSTEM

UPPER RESPIRATORY TRACT-normal

EXAMINATION OF CHEST:
INSPECTION :-
Trachea appears to be central in position
Apical impulse not visible
Chest bilaterally symmetrical
Bilateral Chest movement equal
No paradoxical chest movement.
PALPATION:-

Trachea is confirmed to be central

Apical impulse is present in left 5th ICS on MCL
Chest expansion is 5 cm
Vocal fremitus is normal
There is no Intercostal tenderness
PERCUSSION :-
Direct percussion over clavicle is normal bilaterally
Percussion over left and right hemithorax is
normally resonant

AUSCULTATION :-
Normal bilateral vesicular breath sound heard.
Normal vocal resonance bilateral.
No adventitious sound.
EXAMINATION OF GI SYSTEM
Mouth and oral cavity normal.
INSPECTION:-

Shape of abdomen is normal

Umbilicus central & inverted
Midline scar present below umbilicus
PALPATION:-

Liver not enlarged, Spleen not palpable

PERCUSSION:-
Abdomen is tympanitic.
no shifting dullness
AUSCULTATION:-
Bowel sound 3/min
SUMMARY
PROVISIONAL DIAGNOSIS
Hypo kinetic movement disorder due to young onset Parkinson’s
disease
Extramedullary intradural compressive myelopathy involving
corticospinal, posterior column and lateral spinothalamic tract at
T 10 vertebra due to meningioma.
DIFFERENTIAL DIAGNOSIS

MSA C
WILSON
INVESTIGATIONS
FINAL DIAGNOSIS
THANK YOU