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Movement disorders is a subspecialty field of neurology concerned with patients who either move too much or not enough. This text and its accompanying CD are not designed to serve as a basic textbook of movement disorders. Several excellent texts are already available to satisfy this need. Rather, this book focuses on an interesting and, we think, underrepresented area within movement disorders: movement...
Patient 1: A 75-year-old woman with a history of bipolar affective illness dating back to her 20s was admitted to the hospital after falling and breaking her hip while walking her dog. She had been living alone. She underwent a total hip replacement without incident and was at her mental and physical baseline in the recovery room and then on the postsurgical floor. Two days after surgery...
A 44-year-old right-handed man with a 14-year history of Parkinson’s disease (PD) presented to the emergency department with an acute onset of fever, confusion, rapidly progressive difficulty with ambulation, and dysphagia. He presented initially in 1987 with left upper limb tremor and slowness. Work-up for secondary parkinsonism was unrevealing, and treatment was initiated first with anticholinergic...
Patient 1: A-16-year-old woman, who lives on a farm and spends time outdoors had been well with no psychiatric history until 1 week prior to admission. At that time, she developed difficulty sleeping and bizarre behavior including assault, sobbing, undressing in public, and thoughts of suicide that prompted admission to the hospital. On examination, she is labile, agitated, and delusional...
Patient 1: A 27-year-old woman with a personal and family history of bipolar disorder has taken no psychiatric medications for the past 6 months. One week prior to admission, she develops elevated mood, pressured speech, and flight of ideas. Over the ensuing days, she grows markedly agitated and unable to sleep, talks constantly, paces relentlessly, and refuses to eat or drink. On admission...
Patient 1: A 55-year-old woman was admitted to our hospital because of progressive parkinsonism. She was diagnosed with striatonigral degeneration. Because of nocturnal snoring, a fiberoptic laryngoscopy was performed during wakefulness, showing a mild abduction restriction of the vocal cords. Arterial blood gas analysis was normal. Over the next year, she developed inspiratory stridor during...
A 52-year-old man was transferred to the emergency room of a major hospital from a referral facility because of recent slurred speech. He had been admitted to the facility the week before for treatment of alcohol abuse. Upon his arrival in the emergency room, the neurology resident was called to evaluate the patient after a normal computed tomography scan was obtained. Examination revealed normal...
Patient 1: A 16-year-old non-Jewish boy had an 8-year history of idiopathic torsion dystonia resulting from the DYT1 mutation. At baseline, he was able to sit upright in a chair, but required help with activities of daily living, including feeding, dressing, and bathing. Treatment with a combination of baclofen, trihexyphenidyl, and clonazepam alleviated some of his symptoms. Trials of levodopa,...
Patient 1: A 6-year-old boy presented to the outpatient department for head tilt. Since the age of 2, head tilt to the right side had been noted. When he was 4 years old, cervical spine imaging was performed. Congenital laminar fusion on the right at the C2-3 vertebrae was found. At age 6, posterior in situ fusion of the C2-3 vertebrae with iliac bone graft was performed. However, head tilt...
Patient 1: A 26-year-old man with severe juvenile parkinsonism was maintained on a regimen of levodopa and pergolide. He was admitted to the hospital in order to adjust his Parkinson’s disease medications, and pergolide was tapered off. The neurologist was called to the bedside when he subsequently experienced an acute episode of painful turning of his neck to the right and elevation of...
Patient 1: A 69-year-old man was followed at the Toronto Western Hospital with a 7-year history of Parkinson’s disease (PD). Other past medical history included diabetes, coronary artery disease, and a previous stroke involving the right frontal lobe. Two weeks before presentation, he noticed the acute onset of involuntary movements of the left side, predominantly affecting the arm but also...
A 12-year-old boy developed hyperthyroidism secondary to Grave’s disease, which was successfully treated with I-131 treatment. Several months later, pharyngeal infection with group A β-hemolytic Streptococcus was documented by throat culture and subsequent rise in antistreptolysin O titer. He was treated with oral antibiotics, and 2 weeks later developed insidious, progressive chorea, incoordination...
A 69-year-old woman presented with a 1-year history of low back and leg pain accompanied by progressive difficulty walking. Lumbar surgery was undertaken for spondylolisthesis and canal stenosis. Postoperatively, the pain improved but her walking continued to deteriorate. She then developed spasms of the back and right leg causing flexion of the trunk, hip, and knee. Her mobility deteriorated further...
Patient 1: The parents of a 16-year-old boy ask that their son be urgently evaluated for an exacerbation of his tics. He was diagnosed with Gilles de la Tourette’s syndrome (GTS) at age 5 years and never required pharmacotherapy for his tics. Since the start of the school year and the transition to junior high school, he has developed frequent grunting, coughing, and shouting. These vocal...
The following five patients illustrate the problem of malignant motor tics. Patient 1: Patient with Gilles de la Tourette’s syndrome (GTS) who, in addition to motor tics, exhibits loud vocalizations and screams which have markedly impaired his quality life. His mother has only blinking tics.
Patient 1: A 34-year-old woman had a history of migraine with aura since age 16 and recent postpartum depression. Approximately 6 months ago, she started fluoxetine for depression and migraine prophylaxis. At her most recent clinic appointment, she also started sumatriptan to abort her migraines. Two weeks later, 1 hour after her third subcutaneous 6-mg dose of sumatriptan, she presented...
A neurological consultation is requested in the neonatal intensive care unit for a newborn infant who is noted to be extremely jittery. On examination, the baby is neurologically normal except for exaggerated response to tactile and auditory stimuli, lack of habituation on nose tap, and an exaggerated and sustained Moro response. Resting tone is markedly increased, particularly in axial muscles. On...
Patient 1: A 26-year-old man presented to a neurologist with a 6-month history of mild upper extremity tremor. He also felt that during the past year his memory was not as good as it used to be, and sometimes he had difficulty focusing mentally on tasks. Otherwise, the patient had been healthy. His family history revealed two ancestors on his mother’s side who had had mild tremor. Physical...
Patient 1: A 6-year-old girl with gait disturbance was introduced by an orthopedist in 1990, before the discovery of causative genes in dopa-responsive dystonia (DRD). Although early motor development was normal, she had Trendelenburg’s symptoms resulting from a congenital dislocation of the left hip (acetabular dysplasia). In addition, she developed flexion-inversion of the left foot at...
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