Makindo Medical Notes

History Taking

• Onset and Duration:
  • When did the abnormal movement start? Was it sudden or gradual?
  • Is it continuous or intermittent? Has it progressed over time?
• Character of Movement:
  • Type of movement (e.g., tremor, chorea, dystonia, myoclonus, tics).
  • Is it rhythmic or jerky? Fast or slow? Symmetrical or asymmetrical?
• Triggers and Relieving Factors:
  • Are there any triggers (e.g., stress, caffeine, sleep deprivation)?
  • Do rest, movement, or specific postures influence the movement?
  • Does alcohol or medication improve or worsen the symptoms?
• Associated Symptoms:
  • Ask about other neurological symptoms (e.g., weakness, sensory loss, cognitive impairment).
  • History of trauma, infections, or systemic illness?
• Family History:
  • Any family history of similar movements or neurological disorders?
• Medications and Substance Use:
  • Review medications (e.g., antipsychotics, antiepileptics, or lithium).
  • Inquire about alcohol or drug use.

Physical Examination

• Observation:
  • Observe the patient at rest and during movement. Look for specific involuntary movements.
  • Assess for symmetry, speed, and the affected body parts (e.g., limbs, face, trunk).
• Neurological Examination:
  • Evaluate muscle tone, strength, reflexes, and coordination.
  • Check for Parkinsonian signs (rigidity, bradykinesia), cerebellar signs (ataxia, dysmetria), or pyramidal signs (hyperreflexia, spasticity).
• Posture and Gait:
  • Examine for abnormal postures or gait disturbances (e.g., dystonia, ataxia).

Differential

Investigations

• Laboratory Tests:
  • Basic blood tests: CBC, electrolytes, glucose, calcium, liver, and renal function.
  • Consider thyroid function tests for hyperthyroidism-induced tremor.
  • Wilson's disease: Serum ceruloplasmin, 24-hour urinary copper.
• Imaging:
  • MRI or CT scan of the brain to rule out structural lesions (stroke, tumour, demyelinating disease).
• Genetic Testing:
  • Consider in cases of hereditary movement disorders (e.g., Huntington’s disease).
• Electrophysiology:
  • Electromyography (EMG) or nerve conduction studies to assess for neuromuscular causes.
  • EEG if seizures or myoclonus are suspected.

Management

• Identify and Treat the Underlying Cause:
  • If secondary to a medical condition (e.g., hyperthyroidism, metabolic disorder), treat the underlying cause.
  • Discontinue or modify any offending medications (e.g., antipsychotics, antiemetics).
• Symptomatic Treatment:
  • Essential Tremor: Beta-blockers (e.g., Propranolol), Primidone.
  • Parkinsonism: Dopaminergic drugs (Levodopa, dopamine agonists).
  • Dystonia: Botulinum toxin injections for focal dystonia, anticholinergics (e.g., Trihexyphenidyl).
  • Tics: Alpha-agonists (e.g., Clonidine), antipsychotics for Tourette syndrome.
• Non-Pharmacological Management:
  • Physical and occupational therapy for motor control and functional improvement.
  • Cognitive behavioural therapy for functional tics or stress-related movements.
• Surgical Management:
  • Consider deep brain stimulation (DBS) for refractory cases of Parkinson's disease, essential tremor, or dystonia.