A 70 yr old female with involuntary movements in upper and lower limb

 MEDICINE E LOG BOOK

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CHIEF COMPLAINT

Altered sensorium since 12:00 am midnight, involuntary movement in upper and lower limb since 12:00 am, loss of speech after 12:00 am

HISTORY OF PRESENTING ILLNESS

Pt was apparently asymptomatic 2days ago then she developed b/l involuntary movements in upper and lower limb,  loss of speech and recognition of people. Associated with drooling of frothy saliva from mouth,up rolling of eyes, biting of tongue.  No h/o fever,nausea, vomiting, headache, blurring of vision, diarrhoea, constipation. No postictal confusion

PAST HISTORY

K/c/o DM since 2 yrs and on medication

Not a k/c/o epilepsy, asthma, HTN, tuberculosis

No H/o previous surgeries


PERSONAL HISTORY

Diet: mixed

appetite: normal.

sleep: adequate, 

b&b movt: regular

addiction: tobacco  chewing 


FAMILY HISTORY  no significant family hisory

General examination

Pt is drowsy  E4VIM4

No pallor, icterus, cyanosis, clubbing generalized lymphadenopathy and oedema













Vitals

Bp 150/100 mmhg

Pulse 97 bpm

RR 20 cpm

Temperature 98.6

Spo2 94

Grbs 135 mg/dl (when measured in causality) ( ambulance driver gave history  of grbs 12 mg/dl at her home,started 25% dextrose)



SYSTEMIC EXAMINATION 

CNS 

                         Upper limb                               lower limb

                       Rt                    left               Rt            left

Tone     normal       normal      increased increased

Power           3/5                   3/5             3/5              3/5

Reflexes         right                left

Biceps              ++                   ++

Triceps            ++                   ++

Supinator       ++                   ++

Knee                ++                   ++

Ankle   

Plantar         flexon        extension 

https://youtube.com/shorts/-7N-84kWxAI?feature=share

Neck stiffness +

Kerning sign -

Brudzinski sign -


CVS S1,S2 +,no added murmurs

R/S NVBS heard

P/A  soft and non tender


Provisional diagnosis

?hypoglycemia 

? Viral encephalitis 

? Meningism


INVESTIGATIONS










23/9/22

Diagnosis Altered sensorium 2° to recurrent hypoglycemia  resolved

WITH KNOWN CASS OF DM2

WITH CHOLELITHEASIS

WITH LEFT RENAL CORTICAL CYST
?WITH AKI ON CKD

No fresh complaints

On examination   pt is conscious 
Bp 110/80
PR 82bpm
Temp 98.5°f
CVS s1 s2 +
R/s BLAE +
P/A SOFR NON TENDER

Rx
Oral fluids 3 to 4L/day
Tab GLIPIZIDE 5mg od
Vital monitoring 


Advice at discharge 

Tab GLIPIZIDE 5mg once daily at 2pm

Tab ZINCOVIT once daily at 2pm

Oral fluids 3to 4 lts/day

Review to opd after 10 days 


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