February case (Full Version)

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Dr.Wagner -> February case (January 31, 2008 3:58:36 AM)

35 year old woman presents with involuntary movement of her head and neck rotating specifically to the right.  She also notes that it is difficult to speak and she feels her heart beat fast.  But most distressing to her is the movement of the head. 
She states "I can move it back to the middle...but I involuntarily rotate to the right".


jma -> RE: February case (January 31, 2008 4:10:40 AM)

When did this begin and how long has it lasted? Any significant medical history/recent illnesses? Presently on any kind of medication?

bonez -> RE: February case (January 31, 2008 4:48:58 AM)

Had a youngster present years ago with a"positional" torticollis like this. When you add in my experience with the little one to the rapid heart rate difficulty with speech I'm thinking CNS. Where there other cranial nerve signs?
The little guy (8 months) old had raised ICP that was due to a growth in his third or fourth ventricle. The pressure caused downward pressure on the brainstem producing torticollis .

tucker -> RE: February case (February 1, 2008 2:34:05 PM)

To add on to JMA, any history of psychiatric conditions and/or drugs?

I may be throwing out a zebra here...but could be an acute dystonic reaction with the torticollis-type movement disorder.

Reference:  Advances in Psychiatric Treatment (2000) 6: 332-341
Assessment of drug-related movement disorders in schizophrenia


tucker -> RE: February case (February 1, 2008 8:19:49 PM)

What does the full neurological exam reveal?

The neck dystonia doesn't have to be related to a drug.  Cervical dystonia, or spasmodic torticollis, can occur without a cause.  She's in the age range. 

Dr.Wagner -> RE: February case (February 2, 2008 1:40:01 PM)

Neurologic exam is difficult due to the facial grimacing and head rotation.  Though the patient can move all 4 extremities, responds to pain, and there is no sensory abnormalities.

The patient is very diaphoretic, appears to be in distress. 
Family is very concerned the patient is having a stroke.   But this has been going on for hours now.

Medical History: drug use, distant history of kidney stone.
Social: etoh, tobacco, history of drug use.
Medications: non prescribed.

Is there a concensus thought?
Is the patient having a stroke?


tucker -> RE: February case (February 2, 2008 3:54:18 PM)

Abnormal vitals? 

Sounds like a CVA or some type of drug toxicity with the focal dystonia.

Dr.Wagner -> RE: February case (February 2, 2008 4:19:02 PM)

Well...what do we do?

Do I rush the patient to CT?
Do I do tests?
Is the patient faking?


tucker -> RE: February case (February 2, 2008 5:50:45 PM)

Brain CT to rule out CVA is my first thought.

jma -> RE: February case (February 3, 2008 5:18:44 PM)

There is something about the wrist in the photo that gets my attention. Is their a flapping tremor associated with that hand/wrist photo as well?

Dr.Wagner -> RE: February case (February 3, 2008 10:55:13 PM)

a twisting movement to the hand.
Unfortunately... a CT cannot be performed as there is too much movement.

Tom Reeves DPT ATC -> RE: February case (February 4, 2008 2:29:08 PM)

How do you diagnose Huntington's chorea, I know that you have to have testicles to get it but is there a female version?  I would refer to a neurologist.

Dr.Wagner -> RE: February case (February 4, 2008 6:29:54 PM)

It sounds like there are alot of different thoughts...I will give the answer tonight or tomorrow.  To summarize.

Patient in distress, asking or rather screaming for help.
Acute onset.
Patient is alert and oriented.
Facial grimacing, head rotation, movement of hands.
Able to move all 4 ext.
Sensory intact.
Would his medical and social history have anything to do with it?

Dr.Wagner -> RE: February case (February 5, 2008 1:38:21 PM)

Acute Dystonic Reaction

This patient snorted medication that he got from a friend, not an uncommon occurance, thinking this medication was vicodin.  It was likely an antidepressant or an antipsychotic such as Geodon or Zyprexa. 
Patients often times snort narcotics to get a quicker high...

In this case, the acuity of onset, and the hallmark presentation are the keys.
No testing is necessary, only an acurate history and treatment.

  • Physical examination findings may include any of the following:
    • Oculogyric crisis, deviation of eyes in all directions
    • Buccolingual crisis
    • Protrusion of tongue
    • Trismus
    • Forced jaw opening
    • Difficulty in speaking
    • Facial grimacing
    • Torticollis, usually associated with oculogyric and buccolingual crisis
    • Opisthotonic crisis
    • Lordosis or scoliosis
    • Tortipelvic crisis - Typically involves hip, pelvis, and abdominal wall muscles, causes difficulty with ambulation
  • Mental status is unaffected.
  • Vital signs are usually normal.
  • Remaining physical examination findings are normal.
Pathophysiology Although dystonic reactions are occasionally dose related, these reactions are more often idiosyncratic and not predictable. They appear to result from drug-induced alteration of dopaminergic-cholinergic balance in the nigrostriatum (ie, basal ganglia). Most drugs produce dystonic reactions by nigrostriatal dopamine D2 receptor blockade, which leads to an excess of striatal cholinergic output. High-potency D2 receptor antagonists are most likely to produce an acute dystonic reaction. Agents that balance dopamine blockade with muscarinic M1 receptor blockade are less likely to produce a dystonic reaction. Paradoxically, an alternative cause of dystonic reactions may be increased nigrostriatal dopaminergic activity that occurs as a compensatory response to dopamine receptor blockade.

Tom Reeves DPT ATC -> RE: February case (February 5, 2008 5:08:15 PM)

all that from a young caveman.  Thanks chaka  that was a good one.  One us PTs should punt anyway.

tucker -> RE: February case (February 5, 2008 6:48:07 PM)

....and I thought I was throwing out a zebra answer in post #4.  Thanks!

Shill -> RE: February case (February 5, 2008 7:17:00 PM)

WWCD?  What would Chaka do?  Probably run and get Will.  Maybe Holly, but I doubt it.

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