A case of Titubation

60 year old lady who is a farmer , came to our opd with history of 

1- head nodding since 6 years 

2-neck pain since 6 years 

3- occipital headache since 6 years 

patient was apparently assymptomatic 7 years back and lost her husband in a RTA following which during their property  distribution she suffered physical (had h/o trauma ,loss of consciousness for brief period  and no post traumatic confusion,no ENT  bleed ,no vomiting) and mental trauma

After 6 months of this episode, patient noticed head nodding insidious onset gradually progressive that aggravates with stress,resolves during sleep and decreases in intensity during work.

Associated with vocal tremors and neck pain- which is dragging type radiating to shoulder , aggravates with head nodding ,there is also restriction of neck movements to either side .

-headache in the occipital region and bilateral temporal region ,dragging type since 6 years,phono phobia +, no photophobia or ,giddiness-

no tremors of hands and legs,no difficulty in walking , no difficulty in holding objects, no slippage of foot wear, no washbasin attacks,no difficulty in differentiating hot and cold,no cotton wool sensation,no double vision,no difficulty in closing eyelids,no drooling of food particles from angles of mouth,no difficulty in chewing,swallowing  

not a k/c/o DM,HTN,epilepsy,asthma,TB

Personal history:

Appetite:normal

Bowel and bladder :regular

Chews Beetle nut from 10 years 

No relevant family history of Tremors.

Pallor +

Cyanosis-

Lymphadenopathy-

Icterus-

Clubbing-

Oedema-

Pr:64

Bp:100/60

Spo2:99%

CNS examination :

HMF - intact 

Motor system - 

Tone - normal in both upper and lower limbs 

Power -5/5 in all limbs .

Reflexes:      Right. Left 

        biceps       +2. +2 

        triceps     +2. +2  

        supinator   +2. +2 

         Knee.      . +2. +2

          Ankle. 1+. 1+

                               

   Planters-flexors-+

Sensory,cranial nerves , Cerebellar system - intact .

Musculoskeletal system-neck movements-restricted lateral movements on either side .

Provisional diagnosis-head nodding +   Vocal tremors +, 

                                     ?essential tremors

Treatment-1)tab propranolol 20mg/po/bd

                    2)tab myospas/po/bd

                    3)tab ultracet/po/qid