78 Chorea
Patient 1: Sydenham’s chorea
Salient features
History
• Ask about sore throats if the patient is an adolescent, particularly if female; suspect Syndenham’s chorea (St Vitus dance) in rheumatic fever.
• Take a family history (especially in the middle-aged adult) for Huntington disease.
• Take a history of oral contraceptive use in a young woman or recent pregnancy (chorea gravidorum).
Examination
• Irregular, jerking, ill-sustained, unpredictable, quasipurposive movements of the upper limbs
• The patient is clumsy and keeps dropping objects. Patients with mild disease may show increased fidgeting or restlessness.
• Check the grip of the hands: ask the patient to squeeze your fingers. A squeezing and relaxing motion occurs, which has been described as a ‘milkmaid’s grip’.
• Look at the tongue for any involuntary movements: known as ‘jack-in-the box’ tongue or ‘bag of worms’.
• Test deep tendon reflexes (‘pendular’ or ‘hung-up’ reflexes).
• Tell the examiner that you would like to make enquiries to assess mental status (to exclude premature dementia seen in Huntington disease).
