Case History #168

Date of Consultation: 4-10-2010

HISTORY OF PRESENT ILLNESS:

This 59-year-old right-handed African-American male with a past medical history of alcohol abuse and polysubstance abuse was admitted to the hospital on 4-12-2010 because of right-sided involuntary movements.  Approximately two weeks prior to admission, he noted the onset of abnormal, involuntary movements of the right upper and lower limbs.  These movements occurred approximately every five minutes, and on one occasion he fell while walking upstairs because of these movements.  He has no control over them, although he can subdue them somewhat if he holds his right arm with his left hand.  No involuntary facial movements have been present during the past two weeks.  No impairment of awareness or consciousness accompanied these movements. 

He went to the emergency room of another hospital two days prior to admission (4-10-2010) complaining of chest pain as well as the right-sided movements.  At that time, his alcohol level was quite high, and the emergency room physicians noted that the right-sided movements were present mainly when they were examining the patient.  Therefore, they finally discharged him home to follow-up in Neurology Clinic as soon as possible.  The patient came to our emergency room today because the movements have continued. 

The patient denies any history of hypertension and diabetes, but he does use tobacco.  However, in the emergency room, his blood pressure was 191/107.  The patient was admitted to the hospital for further evaluation.    

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  No deficits of orientation, speech, or memory were present.  The patient’s mood was unremarkable. 

Cranial Nerves:  Intact.

Motor System:  There were no areas of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal in all 4 limbs.  Involuntary movements were noted in the right upper and lower limbs, with the upper limb being more involved than the lower limb.  These movements ranged from rapid, irregular jerking and writhing movements of the limbs to coarse, wide excursion, irregular flinging movements of the limbs, especially when he was somewhat anxious.  The patient was able to partially suppress these movements for short periods of time by relaxing and by holding his right arm with his left hand.

Reflexes:  Deep tendon reflexes were equal and symmetric bilaterally, and the plantar reflexes were flexor bilaterally. 

Sensory System:  All modalities of sensation were perceived normally bilaterally. 

Cerebellar Function:  In between episodes of right-sided involuntary movements, cerebellar tests were performed normally bilaterally.

Gait and Stance:  Not tested.

Questions:

1.  Is there evidence of pyramidal system involvement in this case? 

2.  How would you classify this patient’s involuntary right-sided movements? 

3.  Indicate the specific structures involved by the pathologic process, including the side of involvement. 

4.  In general, what type of pathologic process do you think is involved in this case?

5.  What diagnostic procedures(s) would you undertake at this point?