Movement Disorders Neurology Clerkship.pptnjms.rutgers.edu/psychiarty_neurology/pdf/Movement_Disorders... · ¾OnexaminationhehassloweyeOn examination he has slow eye ... neurologic

MovementMovementMovement Movement DisordersDisordersDisordersDisordersMachteld E. Hillen, M.D.Machteld E. Hillen, M.D.

Assistant Professor Assistant Professor Department of Neurology and Department of Neurology and

NeurosciencesNeurosciences

Case 1Case 1A 50 year old man is admitted to GA 50 year old man is admitted to G--Yellow Yellow with psychosis. He was a partner in awith psychosis. He was a partner in awith psychosis. He was a partner in a with psychosis. He was a partner in a successful law firm until half a year ago, successful law firm until half a year ago, when he suddenly retired to investigatewhen he suddenly retired to investigatewhen he suddenly retired to investigate when he suddenly retired to investigate the Lincoln assassination, which he the Lincoln assassination, which he believes is a communist conspiracy. Hebelieves is a communist conspiracy. Hebelieves is a communist conspiracy. He believes is a communist conspiracy. He spent all his family savings and goes spent all his family savings and goes bankrupt. He is found wondering in thebankrupt. He is found wondering in thebankrupt. He is found wondering in the bankrupt. He is found wondering in the streets of the Ironbound. He is psychotic, streets of the Ironbound. He is psychotic, delusional, very fidgety and cannot sit still.delusional, very fidgety and cannot sit still.delusional, very fidgety and cannot sit still.delusional, very fidgety and cannot sit still.

Case 1Case 1Case 1Case 1

On examination he has slow eyeOn examination he has slow eyeOn examination he has slow eye On examination he has slow eye movement with inability to suppress head movement with inability to suppress head movement He cannot protrude his tonguemovement He cannot protrude his tonguemovement. He cannot protrude his tongue movement. He cannot protrude his tongue for more than 5 seconds. He has for more than 5 seconds. He has continuous movement of his pelvis andcontinuous movement of his pelvis andcontinuous movement of his pelvis and continuous movement of his pelvis and limb girdle and there is posturing of the left limb girdle and there is posturing of the left foot There is mild rigidity noted on thefoot There is mild rigidity noted on thefoot. There is mild rigidity noted on the foot. There is mild rigidity noted on the upper extremities and he has a tendency upper extremities and he has a tendency to fall backwardsto fall backwardsto fall backwards.to fall backwards.


What is this patients most likely diagnosis?What is this patients most likely diagnosis?What is this patients most likely diagnosis?What is this patients most likely diagnosis?What is the difference between chorea What is the difference between chorea and athetosis?and athetosis?and athetosis?and athetosis?What other (reversible) causes of chorea What other (reversible) causes of chorea d k ?d k ?do you know?do you know?


A 68 year old female with a history of HTNA 68 year old female with a history of HTNA 68 year old female with a history of HTN A 68 year old female with a history of HTN and DM is brought to the ER with and DM is brought to the ER with involuntary arm movements that have involuntary arm movements that have yybeen present for 3 hours. She is been present for 3 hours. She is completely coherent. completely coherent. On examination, you notice wild flinging On examination, you notice wild flinging arm movements that seem involuntary. arm movements that seem involuntary. Th i d f h iTh i d f h iThe remainder of a comprehensive The remainder of a comprehensive neurologic exam is normalneurologic exam is normal


What is this phenomena called?What is this phenomena called?What is this phenomena called?What is this phenomena called?Where do you localize the lesion?Where do you localize the lesion?Wh t i th diff ti l di i ?Wh t i th diff ti l di i ?What is the differential diagnosis?What is the differential diagnosis?What is the prognosis and how would you What is the prognosis and how would you be able to treat this?be able to treat this?

L i i thL i i thLesion in the Lesion in the Subthalamic Subthalamic Nucleus (right)Nucleus (right)


A 61A 61--yearyear--old woman with no prior medicalold woman with no prior medicalA 61A 61 yearyear old woman with no prior medical old woman with no prior medical problems has noticed tremor and loss of problems has noticed tremor and loss of manual dexterity in the right hand formanual dexterity in the right hand formanual dexterity in the right hand for manual dexterity in the right hand for about 6 months. Her husband noticed that about 6 months. Her husband noticed that she does not swing her right arm whenshe does not swing her right arm whenshe does not swing her right arm when she does not swing her right arm when she walks and that tremor is often present she walks and that tremor is often present in the right arm when she walksin the right arm when she walksin the right arm when she walks. in the right arm when she walks.


Examination revealed cogwheel rigidity inExamination revealed cogwheel rigidity inExamination revealed cogwheel rigidity in Examination revealed cogwheel rigidity in the arm. A resting tremor was the arm. A resting tremor was intermittently present in the right handintermittently present in the right handintermittently present in the right hand, intermittently present in the right hand, particularly when she walked or particularly when she walked or concentrated on mental status questionsconcentrated on mental status questionsconcentrated on mental status questions. concentrated on mental status questions. There was decreased arm swing in the There was decreased arm swing in the right arm But gait and posture wereright arm But gait and posture wereright arm. But gait and posture were right arm. But gait and posture were otherwise normal.otherwise normal.

Michael J FoxMichael J FoxMichael J FoxMichael J Fox


Why is this not essential tremor?Why is this not essential tremor?Why is this not essential tremor?Why is this not essential tremor?Are there any “red flags”, suggesting a Are there any “red flags”, suggesting a diagnosis other than Parkinson’s disease?diagnosis other than Parkinson’s disease?diagnosis other than Parkinson s disease?diagnosis other than Parkinson s disease?What are the treatment options at this What are the treatment options at this point?point?point?point?What is the long term prognosis? Is it What is the long term prognosis? Is it likely that she will die from her condition?likely that she will die from her condition?likely that she will die from her condition?likely that she will die from her condition?How can you differentiate Parkinson’s How can you differentiate Parkinson’s Disease from Parkinsonism?Disease from Parkinsonism?Disease from Parkinsonism?Disease from Parkinsonism?

Case 4Case 4Case 4Case 4??????????????????


What do the previous pictures show?What do the previous pictures show?What do the previous pictures show?What do the previous pictures show?

Wh t h i thi t di d ?Wh t h i thi t di d ?What happens in this movement disorder?What happens in this movement disorder?

What can you do to help your patient?What can you do to help your patient?

How are these patients misdiagnosed?How are these patients misdiagnosed?


You are asked to see a 63 year old man inYou are asked to see a 63 year old man inYou are asked to see a 63 year old man in You are asked to see a 63 year old man in the CCU for seizures. The patient was the CCU for seizures. The patient was brought in earlier when he collapsed onbrought in earlier when he collapsed onbrought in earlier when he collapsed on brought in earlier when he collapsed on the street. EMS was called by bystanders the street. EMS was called by bystanders and patient was resuscitated andand patient was resuscitated andand patient was resuscitated and and patient was resuscitated and intubated in the field. Upon arrival to the intubated in the field. Upon arrival to the ER he had a normal sinus rhythm and didER he had a normal sinus rhythm and didER he had a normal sinus rhythm and did ER he had a normal sinus rhythm and did not need sedation, despite the fact that he not need sedation, despite the fact that he was intubatedwas intubatedwas intubatedwas intubated


On exam you see an intubated man whoOn exam you see an intubated man whoOn exam you see an intubated man, who On exam you see an intubated man, who has a brief jerk over his entire body, which has a brief jerk over his entire body, which occurs whenever he receives a breathoccurs whenever he receives a breathoccurs whenever he receives a breath occurs whenever he receives a breath from the ventilator. He does not respond to from the ventilator. He does not respond to verbal or painful stimuli He has bilateralverbal or painful stimuli He has bilateralverbal or painful stimuli. He has bilateral verbal or painful stimuli. He has bilateral upgoing toes.upgoing toes.



What is the name of the movement thatWhat is the name of the movement thatWhat is the name of the movement that What is the name of the movement that was described?was described?Why does this patient have theseWhy does this patient have theseWhy does this patient have these Why does this patient have these movements?movements?What other medical conditions can causeWhat other medical conditions can causeWhat other medical conditions can cause What other medical conditions can cause this movement?this movement?Which neurologic conditions can causeWhich neurologic conditions can causeWhich neurologic conditions can cause Which neurologic conditions can cause this movement?this movement?How can you treat the movements?How can you treat the movements?How can you treat the movements?How can you treat the movements?

Classification of MyoclonusClassification of MyoclonusClassification of MyoclonusClassification of Myoclonus

Causes of MyoclonusCauses of MyoclonusCauses of MyoclonusCauses of Myoclonus


A mother brings her 8 year old son to yourA mother brings her 8 year old son to yourA mother brings her 8 year old son to your A mother brings her 8 year old son to your office for an evaluation. A year ago he had office for an evaluation. A year ago he had a cough for which you prescribed a cough for which you prescribed g y pg y pantibiotics twice, without relief. The cough antibiotics twice, without relief. The cough eventually resolved spontaneously after a eventually resolved spontaneously after a f thf thfew months. few months. Now she notices that he is developing a Now she notices that he is developing a “ ti ” i hi h h i k“ ti ” i hi h h i k“nervous tic”, in which he winks, “nervous tic”, in which he winks, accompanied by with a brief head motion. accompanied by with a brief head motion.


Upon further questioning he has beenUpon further questioning he has beenUpon further questioning, he has been Upon further questioning, he has been recently evaluated by the school study recently evaluated by the school study team because of poor performance inteam because of poor performance inteam because of poor performance in team because of poor performance in school.school.Your exam is normal and you do not seeYour exam is normal and you do not seeYour exam is normal and you do not see Your exam is normal and you do not see the nervous tic.the nervous tic.


What is your diagnosis?What is your diagnosis?What is your diagnosis?What is your diagnosis?Which concomitant conditions can you see Which concomitant conditions can you see in these patients and their familyin these patients and their familyin these patients and their family in these patients and their family members?members?H b t t t thi hild?H b t t t thi hild?How can you best treat this child?How can you best treat this child?Why were you not able to see the Why were you not able to see the abnormal movements in your office?abnormal movements in your office?

Tourette’s SyndromeTourette’s SyndromeTourette s SyndromeTourette s Syndrome

Useful WebsitesUseful WebsitesUseful WebsitesUseful Websites

www.wemove.orgwww.wemove.org (watch the video clips)(watch the video clips)

www.mdvu.orgwww.mdvu.org (for Healthcare (for Healthcare professionals)professionals)

Documents

Movement Disorders Neurology Clerkship.pptnjms.rutgers.edu/psychiarty_neurology/pdf/Movement_Disorders... · ¾OnexaminationhehassloweyeOn examination he has slow eye ... neurologic