60 year female with left upper and lower limb involuntary movements 3 days ago

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.

60YR OLD FEMALE PATIENT, RESIDENT OF RAMANAPET,FARMER BY OCCUPATION, CAME TO THE OPD,WITH THE CHIEF COMPLAINTS OF : 

C/O Involuntary movements of Left UL and LL ( first episode ) , associated with frothing ,Uprolling of eyes ,Tongue Bite ,Post Ictal Confusion present for 10 minutes .

Tongue Bite : 

No seizure activity at presentation but H/O two episodes of seizures occured at their home place and at their local Hospital ( at Ramanapet) within 30 minutes of each

 Fever ,which is Sudden in onset and intermittent type  since 2 days associated with chills ,rigors  and head ache behind the eyes,

The episode of seizure occurred after the fever had subsided

Neck pain- dragging type ,diffuse ,present since 2days 

H/O fall from bike 2years ago , led to mild abrasions over body and head  and associated with fracture of LT wrist joint (as she fell over left side -one side) .

No H/O Cold ,Cough , loss of appetite, Diurnal Variation , Burning Micturition 

PAST HISTORY: 


Not a K/C/O HTN, DM II , Epilepsy,Asthma ,TB , CAD ,CVD ,Thyroid 


PERSONAL HISTORY : 

Appetite -Normal 

Diet - Mixed 

Sleep - adequate

Bowel and bladder movements -Regular 

Addictions: Occasional alcoholic ( once every 3days - she consumes 90ml of alcohol )

Betel Nut chewing - Daily for 5-6 times 

Allergies : No allergies 

GENERAL EXAMINATION: 

Patient is conscious ,coherent , cooperative, Moderately Built and Moderately Nourished .

Temp: Afebrile 

BP : 130 / 90 mmHg 

PR : 87bpm 

RR : 20cpm 

GENERAL EXAMINATION:


Pallor : absent 


Icterus : absent 


Cyanosis: absent 


Clubbing : absent 


Lymphadenopathy : absent 


Edema : absent 


SYSTEMIC EXAMINATION: 


CNS : HMF +  


                  RT LT 


Tone : UL : N N


             LL : N N




Power : UL -5/5 5/5


               LL- 5/5 5/5 




Reflexes : biceps: 2+ 2+


                Triceps : 2+ 2+


                   Knee: 2+ 2+


                   Ankle : 1+ 1+


             Supinator : 1+ 1+


              Babinsky : plantar plantar 


                                  Flexion flexion 


CVS : S1 S2 + ,no murmurs 


RS : BAE Present 


P/A : Soft and Non tender 


Meningeal signs like : neck stiffness , kerning sign,brudzinsky sign ared negative 


MRI BRAIN REPORT: 

-Acute Infarcts in Right Precentral Gyrus ,Pre motor area ,middle frontal gyrus ,centrum semi ovale ,Corona Radiata 

- Mild diffuse Cerebral atrophy 


PROVISIONAL DIAGNOSIS: 

FOCAL SEIZURES WITH SECONDARY GENERALISATION 

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