22Y M WITH INVOLUNTARY MOVEMENTS OF HEAD AND UPPER LIMBS

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CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

This is a case of 25 Y Male with 

Complaints of involuntary movements of neck since 4 years 

involuntary movements of upper limb since 1 year 

HOPI

Patient was apparently normal 4 years back then he developed involuntary movements of Neck since 4 years which was insidious in onset and gradually progressive, initially started as fine movements/ tremors. And intensity increased gradually.

He also develop involuntary movements of upper limbs since 1 year insidious in onset and gradually progressive initially left upper limb and then progressive to right upper limb

Complaints of increase in intensity of movements since one week.

No complaints headache seizures, loss of consciousness,Giddiness vision disturbances,fever, vomitings

Tremors are seen only while doing working  and  relieved in resting state.

H/o liver Abscess 1 year back drained and advised for alcohol abstinence. 

Alcohol stopped 15 days back.

Personal history:

Diet: mixed 

Appetite: normal

Sleep: Adequate 

Bowel and bladder: Regular 

No addictions and allergies

GENERAL EXAMINATION:

Vitals:

PR-54bpm

RR- 22cpm

Temp-98.5  

Bp-100/60 mmhg 

Spo2-98 RA 

GRBS-92  mg/dl

No pallor,No icterus, cyanosis, clubbing, lymphadenopathy.  

SYSTEMIC EXAMINATION ::

GIT

INSPECTION :

Abdomen - scaphoid 

Umbilicus - inverted 

Movements - all quadrants are equally moving with respiration

No scars and sinuses 

No visible peristalsis

No engorged veins.

PALPATION:

No local rise in temperature and no tenderness in all quadrants 

LIVER: no hepatomegly

SPLEEN- not enlarged 

KIDNEYS - bimanual palpable kidneys 

PERCUSSION :

no shifting dullness

AUSCULTATION :

Bowel sounds are heard and are normal

No bruit

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical with pectum excavatum 

Type of respiration: thoraco abdominal.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- absent.

Vocal fremitus- normal on both sides.

Percussion:                   

Supraclavicular            

Infraclavicular.         

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Interscapular

Right side and left side- resonant in above areas.

Auscultation:

Bilateral Airway entry - present

Cardiovascular system:

Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

Central Nervous system:

Higher motor functions- Intact 

Speech: slurred

Cranial nerve functions - Normal

Sensory system-Normal

Motor system Right  Left    

                    Power- UL 4/5  4/5

                                      LL 4/5  4/5 

                         Neck Normal 

                 Trunk muscles Normal  

          Tone- UL Normal Normal

                         LL Normal Normal 

          Reflexes- 

Superficial reflexes - Intact 

                             Plantar flexion  flexion

Deep tendon reflexes -

                           Biceps   -    -

                           Triceps   -   -

                         Supinator  -   -

                                Knee  +   + 

                             Ankle  -     - 

INVESTIGATIONS:   

USG(7/5/23)

DIAGNOSIS : 

TREMOR PLUS SYNDROME 

SPASTIC CEREBELLAR ATAXIA 

?GENETC

TREATMENT: 

IV FLUIDS @75 ML/HR 

INJ.METHYLCOBALAMIN 1500MCG IV/OD IN 100ML NS FOR 1 WEEK

TAB.TETRABENZINE 12.5MG PO/OD

CAP.BETACAP TR 40  X DAILY 

TAB.EVION X DAILY

      DISCHARGE SUMMARY:

Final diagnosis :

TREMOR PLUS SYNDROME 

SPASTIC CEREBELLAR ATAXIA 
 

25 Y Male with Complaints of involuntary movements of neck since 4 years

involuntary movements of upper limb since 1 year

Patient was apparently normal 4 years back then he developed involuntary movements of Neck since 4 years which was insidious in onset and gradually progressive, initially started as fine movements/ tremors. And intensity increased gradually.

He also develop involuntary movements of upper limbs since 1 year insidious in onset and gradually progressive initially left upper limb and then progressive to right upper limb

Complaints of increase in intensity of movements since one week.

No complaints headache seizures, loss of consciousness,Giddiness vision disturbances,fever, vomitings

Tremors are seen only while doing working  and  relieved in resting state.

H/o liver Abscess 1 year back drained and advised for alcohol abstinence.

 Alcohol stopped 15 days back

Past history :
Liver Abscess drained 1 yr back.

Course in hospital :

Patient was investigated further and Neurology referral was done where MRI Brain was advised.He's being discharged and asked to follow with the report.