36/F with complaints of involuntary movements of right upper limb.

 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome.

I've 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 a diagnosis and treatment plan.



Chief Complaints:- 

patient came with complaints of involuntary movements of right upper Limb since 1 hour. 


H.O.P.I

Patient was apparently asymptomatic one hour ago, then she developed involuntary movements of right upper Limb not associated with loss of consciousness,Incontinencies(fecal/urinary) vomiting,pain abdomen, fever ,cough ,cold, drooling of saliva,uprolling of eyes,tongue bite, post ictal confusion .

patient was conscious coherent and cooperative during seizures  


Pt. Also has a h/o of similar complaint yesterday night which was associated with 1 episode of vomiting,loss of consciousness with subsidised after injection lorazepam 2cc IV stat. sensorium improved after seizure attack with no post ictal confusion .



PAST HISTORY:-


First seizure attack was 18 years ago which were involuntary movements of right upper Limb and left lower Limb while she was pregnant.

There were episode of similar complaints (6-8 times out of which 3-4 times she had involuntary movements of both  right upper Limb and lower Limb while remaining times she  had involuntary moments of right upper Limb only . 

In the episode  of 2022( 8 months ago) she had was c/c/c  And oriented to time, place and person during the episode and no post ictal confusion.




Past surgical history:- 2 lscs


Personal history:-

Pt. Is a agricultural labour

Appetite:- Normal

Diet- mixed

Bowel & bladder:- regular 

No Addictions


Family history

Not significant






Allergic history

No known allergies




General  examination


Patient is C/C/C.

Pallor-absent 

Icterus-absent 

Cyanosis -absent 

Clubbing-absent 

Lymphadenopathy-absent 

Pedal edema- absent



Malnutrition:- no

Dehydration:- no


Vitals

Temperature:- 98.4°F

Pr:- 76/min

Rr:- 18/min

BP:- 110/70 mmhg

spO2:- 98% at RA

GRBS:- 106mg%




Systemic examination 

CVS:- S1 S2 heard, no murmurs

Rs:- BAE + ,  no added sounds

P/a:- soft, Non-tender, Bowel sounds heard

CNS:- 

  • Pt  was concious
  • Speech:- normal
  • Signs of meningeal irritation ( neck stiffness and kernig sign) :- absent
  • Motor system           Right                  Left  
  •               Tone      UL     N/Increased      N
  •                              LL        N                       N
  •          POWER      UL        5/5                   5/5
  •                              LL        5/5                    5/5

Reflexs 

   Right                Left

Biceps                                  +3                    +2

Triceps                                 +3                    +2

Supinator                             +2                   +2

Knee                                      +2                   +2

Ankle                                     ---                    ---




Provisional Diagnosis :-  Focal seizures with intact awareness .




Investigations:-










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