19/2/22

After yesterdays night duty, Today my day started with camp at  peddasuraram nalgonda dist.

Most of the cases are of osteoarthritis and senile cataracts out of which one interesting case I have come accross is : 

60M shaperd with h/o involuntary movements of both upperlimbs ( Rt more than Lt) since 4 months emotionally outbursted as his involuntary movements hamperd his routine job of looking after Sheeps. He cried while examining and needed medical attention to treat his symptoms so that he can resume his daily routine job. Adviced admission under GM.

Assymetric resting tremors of upper limb ( rt more than left )

Cog wheel rigidity prominent at right wrist joint

Involuntary movements subsiding with voluntary movements.

Discuss around the case through online media : 

[2/19, 10:57 AM] saicharankulakarni: Describing the movement in the following domains -

1. involuntary movements still observed when patient is unaware of some one observing him.

2.Body part affected - upper limbs ( Rt > Lt ) 

3. Frequency of movement (in Hz) - coarse

4. Amplitude of Movement - low amplitude

5. Timing of movement - predominantly at rest and subsided on voluntary movement

6. Aggravated at rest and relieved on voluntary activity

 

Points to be asked : 

7. Does the movement disappear in sleep..??

[2/19, 11:25 AM] saicharankulakarni: World class.

[2/19, 11:25 AM] saicharankulakarni: Also noticing slow turns and reduced arm swing

[2/19, 11:25 AM] saicharankulakarni: No first step phenomenon or peacock phenomenon (the first step triggers a few rapid short steps)

Probable mild stoop forwards.

[2/19, 11:25 AM] saicharankulakarni: How does question 7 help in improving the differential diagnoses list?

[2/19, 11:25 AM] saicharankulakarni: To differentiate weather hyponogogic or hypnopompic sir..!

Weather involuntary movements predominant during bed time or during day time. Jz to name them I guess... Need some time to review and get back sir

[2/19, 11:25 AM] saicharankulakarni: And what would be your differential list after asking that question?

[2/19, 11:25 AM] saicharankulakarni: What is your differential list prior to asking that question?

[2/19, 11:25 AM] saicharankulakarni: With given history and breif examination at camp i provisionally concluded this as tremor which is prominent at rest. 

1. Parkinson tremors ( assymetric resting tremor with bradykinesia, mask like facies ) with emotional outburst and proper examination may be Parkinson plus to be ruled out/ruled in.

2. Essential Tremors

[2/19, 11:25 AM] saicharankulakarni: It is the same sir.. as am thinking of tremors. Usually myoclonus/ dystonias are associated during bed time sir. And also it can differentiate between voluntary and involuntary movements though not confirmative.

Came back by 3.30 pm,. Had lunch and went to admin to submit pending case sheets. 

Took evening rounds and had a bed side discussion with 7th sem ( 3rd yr mbbs) students in 4-6pm on Longitudinal extensive transverse myelitis ( LETM)