60 year old female patient who's a farmer resident of Miryalguda came to our opd with
C/o head nodding since 6 years 
    neck pain since 6 years ,
    occipital headache since 6 years 
patient was apparently asymptomatic 7 years back She lost her husband by RTA following which property distribution she suffered physical trauma ( She had loss of consciousness for brief period  and no post traumatic confusion,no ENT  bleed ,no vomiting) and mental trauma
After 6 months of trauma patient noticed head nodding insidious onset gradually progressive ,aggravates with stress,resolves during sleep and decreased intensity during works
It is associated with slurring of speech ,associated with neck pain-dragging type radiating to shoulder ,numbness ,increased pain during head nodding,restricted neck movement 
-headache in the occipital region and bilateral temporal region ,dragging type since 6 years,phonophobia +
photophobia - giddiness -
There's No tremors of hands and legs,no difficulty in walking , no difficulty in holding objects, no slippage of foot wear,no difficulty in walking in dark , 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  

PAST HISTORY
Not a k/c/o DM,HTN,epilepsy,asthma,TB
Personal history:
Appetite:normal
Bowel and bladder :regular
Chews Beetle nut from 10 years 
Tobacco:-
No relevant family history 
ON EXAMINATION
Pallor +
Cyanosis-
Lymphadenopathy-
Icterus-
Clubbing-
Oedema-

Vitals
Pr:64
Bp:100/60
Spo2:99% at RA
Temp - Afebrile
Grbs - 102 mg/dl

Systemic examination

CVS - S1,S2 +
RS - BAE +
CNS  examination 
Gait-normal
Hmf -intact
Tone    right     left
           UL      N           N
           LL      N           N
Power         5/5         5/5
Reflexes: biceps   triceps  supinator Knee  Ankle
  Right.      +2.            +2        +2           +2          -
  Left         +2               +2          +2      +2          -
Sensory-pain,touch perceived
Cerebellar-
Gait-normal
Nystagmus- negative
Dysdiadikinesia-negative
Finger nose- negative
Cranial nerves intact

  Plantars-
flexors- +
Musculoskeletal system-
neck movements-restricted lateral movements on either side 
flexion and extension - Normal

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

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