CLINICAL INTEGRATION CASE

MARCH 1, TUESDAY 10-12NN

CLINICAL HISTORY:
The patient is a 24 year old right-handed male, who presented with involuntary movement of the right lower extremity of 2 weeks
duration.
2 weeks prior to admission, he noted sudden onset of involuntary movement of the right lower extremity. Initially, his right foot
would occasionally kick then he would notice his right leg would move in a repetitive manner. His sisters observed that it would disappear
during sleep. It was not associated with muscle pain, numbness, or weakness. Due to persistence, patient sought consult.
ROS: (+) Weight loss 70kg from 75 kg in 6 months. No fever, poor appetite. No cough, colds or chest pains. No intermittent changes in
bowel habits, abdominal pain, or vomiting. No bladder or bowel symptoms. No bleeding problems or bipedal edema.
PAST MEDICAL HISTORY:
The patients medical history revealed that he was diagnosed with TB adenitis, which was confirmed by biopsy, last February 2014. He took
HRZE for 6 months. In that same year, he was also diagnosed with Cryptococcal Meningitis, which was confirmed by lumbar tap, and was
treated with Amphotericin B for 4 weeks. He eventually underwent lumbo-peritoneal shunt insertion. On work up, CD 4 count was 9. There
was no history of DM, HTN, BA, or thyroid disease.
FAMILY HISTORY:
There was no family history of DM, hypertension, movement disorders, dementia or psychiatric illness.
PERSONAL AND SOCIAL HISTORY:
He is single, Filipino, Roman Catholic, born in Manila and presently resides in Quezon City.
He occasionally drinks alcoholic beverage and previously a smoker for 8 pack years. He denies history of illicit drug use.
He worked as an IT specialist. He recently travelled to Zambales, Laguna and Bulacan for mountain climbing; he recalled being exposed to
bird droppings. He also went to Singapore for a leisure trip. He refused to answer questions about his sexual history and when he was
asked about any work up for HIV, he became quiet.
PHYSICAL EXAMINATION on ADMISSION:
Conscious, coherent, not in cardiorespiratory distress
BP:
130/70 CR:
78
RR:
21
T:
37.5oC
Anicteric sclera, pink palpebral conjunctivae
Moist lips, no jaundice
Non-hyperemic, non-enlarged tonsils
No cervical lymphadenopathies, no neck vein engorgement
Normal rate, regular rhythm, apex 5th anterior axilla line, no murmurs.
Grossly normal thorax, no intercostal retractions, Symmetrical chest expansion, clear breath sounds
Flat abdomen, normoactive bowel sounds, soft, nontender, no organomegaly, no tenderness
Full peripheral pulses. (-) edema.
NEURO EXAM on ADMISSION
General behavior and appearance: normal, dressed appropriate to age and sex
Stream of talk: converses normally
Mood and affective responses: appropriate to situation
Content of thought: no illusions, delusions, hallucinations
Intellectual capacity: average
Sensorium

Awake, alert

Good attention span

Oriented to name, person and place

Intact recent an remote memory

Good funds of information

Fair insight and intact judgement

Intact calculation
MMSE: 30/30
Able to name, repeat, copy,
No agraphesthesia, no astereognosis, no apraxia.
No right to left disorientation
No agnosias
Cranial Nerves:
l- able to smell coffee
II, III isocoric 2-3mm, reactive; OU: No visual field cuts; Fundoscopy: +ROR; clear media. AV ratio: 2:3. (-)AV nicking; clear disc
borders, no papilledema
III, IV, VI no ptosis,

V no sensory deficit.
Good masseter and temporalis muscle tone.
VII intact muscles of facial expression, no asymmetry
VIII intact gross hearing, webbers test midline,
rinne: AC>BC, bilateral; patient = examiner
IX, X equal palatal elevation, intact gag
XI able to shrug both shoulders, turns head side-to-side
XII protrudes tongue at midline
Motor:
5/5 on all extremities
(-) Muscular Atrophy.
(-) Fasciculations/fibrillations
Non-rhythmic, hyperkinetic movement, most of the time jerky, involving the right foot thigh and leg noted more prominent during
voluntary movement
Normal tone
Sensory
No sensory deficits
Intact position and vibration sense
Reflex: normoreflexive
No clonus, No Babinski, No glabellar tap, palmomental, palmar grasp, snout reflex, rooting reflex.