55 years male with involuntary movements of both upper and lower limbs





THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

A 55 years old male patient came to the casualty with history of in voluntary movements of both upper and lower limbs at 4 AM in an episode at 4:30 AM With Post ictal confusion

HOPI:

He was apparently asymptomatic till today morning (10/2/22) then he developed involuntary movements of both upper and lower limbs at 4 AM in the morning And also post ictal confusion

It is also associated with involuntary defecations

There is a H/o fever since one day which is associated with generalised weakness

It is also associated with tongue bite

No H/o drowning of saliva and involuntary micturition

No H/o vomiting , loose tools


Past history :

History of RTA in 2018 And left temporal lobe conclusion?/Haemorrhage? With acute SAH For which they have done craniotomy plus cranioplasty back in 2018 

He was on Tab. Levipil 500 MG PO/BD For up to 2 years

Since one year he was on Tab.encorate sodium 250MG PO/OD

(levipil to encorate) he is having some aggression issues and ?personality disorder

No history of DM, HTN, epilepsy, TB, CAD, CVA.


PERSONAL HISTORY:

Diet : Mixed

Appetite : normal

Bowel and Bladder moments : regular

Addictions  : he was occasionally alcoholic since 25 years but he stopped after the craniotomy surgery in 2018.

No other known drug allergies 


FAMILY HISTORY: Not significant 


ON EXAMINATION :

patient was conscious , Coherent  , cooperative 

No signs of pallor , ictreus, clubbing , Sinuses lymphadenopathy , pedal edema

VITALS :

Temp : 98.6'F

Bp : 140/90mmhg

Pr  :  95 bpm

Rr  : 19cpm

Spo2 : 96% on room air


SYSTEMIC EXAMINATION:

Cardiovascular system: s1,s2 heard , no murmurs heard

Respiratory system : Bilateral air entry present , normal vesicular breath sounds

Per abdomen : soft , non-tender , no organomegaly

Cns :

Patient is conscious

No Neck stiffness

                                Right     left

  1. Tone of ul : normal.  Normal
  2. Tone of Ll : normla.  Normal
  3. Power   Ul : 4/5.       3/5
  4. Power.   Ll : 4/5.       3/5
  5. Handgrip :  100%
  6. Reflexes : 
  7. A) biceps   1+.         1+
  8. B) triceps.  1+.         1+
  9. C)supinator 1+.        1+
  10. D)knee.       1+.         1+
  11. E)ankle.      1+.         1+
  12. F)plantar.    Extensor flexor









INVESTIGATION:

 

INVESTIGATIONS:

HEMOGRAM: 

HB: 15.9%

TLC: 16,500

N/L/E/M/B: 87/07/02/04/00

PCV: 47.1

MCV: 81.6

MCH: 27.6

MCHC:33.8

RBC:5.77

PT:2.73

RDW-CV :13.1

RDW-SD: 39.8

PS: NC/NC


RFT:

BLOOD UREA : 23mg/dl

SERUM CREATININE: 1.6mg/dl

SERUM ELECTROLYTES:

Na+ : 135

K+: 4.1

Cl-: 98


LFT

TB: 1.07

DB: 0.20

SGOT:24

SGOT:14

ALP: 146

TP:7.6

ALBUMIN:3.6

A/G: 0.91


RBS : 117


Serum Electrolytes :

NA : 138

K+ : 4.2

Cl  : 94


Uric acid : 12.6mg%


SEROLOGY: NEGATIVE

 

Ecg : 

Cxr :

 

               


2D echo : 



https://photos.app.goo.gl/cAdR2BFL1cdoyBMH7

Trival AR+/TR+/MR+

Good LV systolic function 

Diastolic dysfunction + 


MRI BRAIN : 

IMP :

.Encephalomalacic changes with surrounding gliosis in left temporal lobe and left parietal lobe - sequal of old insult

.Mild exvacuo dilation of left lateral ventricle

.post op chnages in the calvarium involving left parietal bone


Treatment: 


1) inj.pan 40mg iv/bd

2) inj.optineuron 1amp in 100ml ns iv /od

3) inj.Na valproate 2g/iv/stat

3)Tab.encroate 300mg/bd




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