July 27, 2021

77 yr old with involuntary movements

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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.

26/7/21:-

A 77 year old male patient presented to the casualty with the complaints of involuntary movements of b/l Upper limb and lower limb yesterday night which lasted for 10 mins (Generalized tonic-clonic seizure type ) associated with loss of consciousness,tongue bite ,with up rolling of eyes frothing from mouth and post ictal confusion for 1hr And not associated with aura ,No involuntary defecation / micturition .presence of slurring of speech after the episode which resolved in 1hr

Past history:- *****10yrs ago patient had complaints of weakness of right upper and lower limb for which he was given medication and they have been using it on and off

Stopped 6months back

*****In 2017 patient had complaints of headache in the occipital region since 2yrs which increased since one month (not associated with giddiness and vomitings)

Also he had complaints of pain in the right knee and was unable to bend his right knee , and complaints of backache.The patient and attendant(wife) could not give clear details about the events

Reports suggest:-

HE IS A K/C/O CVA -Rt.Hemiparesis 3months back and in recovery

The following investigations were advised

1.MRI LUMBAR SPINE

Impression:-
•Diffuse annular bulge at L1-L2 and L2-L3 levels causing mild thecal sac indentation

•Diffuse disc bulge at L3-L4 level causing indentation over thecal sac with narrowing of bilateral neural foramina

•posterior central disc protrusion at L4-L5 level causing indentation over left thecal sac with bilateral neural foraminal narrowing

•Bilateral facetal arthrosis at L4-L5 and L5-S1 levels

2.CT BRAIN:-

Impression:-normal CT

And was prescribed

•T.PANTOP 40mg

•T.PROXYM-ER

•T.NEXPRO-RD

•T.ECOSPRIN

•T.LAMITOR-DT

•T.CALTEN-D

**** IN Jan 2020 patient had complaints of pedal edema since 10days for which he came to our hospital

The discharge summary is as follows

CXR-PA VIEW in Jan 2020

After that that patient was apparently asymptomatic

N/k/c/o DM ,HTN,BRONCHIAL ASTHMA,TB

Personal history :

Normal appetite

Mixed diet

Bowels : constipation -once for 2 days with normal consistence

bladder movements:- : normal

No known allergies

Addictions : Nil

Family history :

No similar complaints in family members

General examination :

On examination :

Patient is conscious , coherent ,and cooperative

Thin built

No pallor

No icterus

No cyanosis

No clubbing

No generalised lymphadenopathy

No pedal edema

Vitals :

Temperature -97 . 5 °F

PR : 84 BPM

RR : 22 cpm

BP : 100/80 mm Hg

Spo 2: 98% on RA

GRBS : 112 mg/dl

Systemic examination :

CVS:-

S1 and S2 heard No murmurs

Respiratory system :

Normal vesicular breath sounds

No respiratory crepts

Per abdomen :

Soft ,no tender

CNS EXAMINATION:-

No focal deficit seen

Reflexes are normal

Provisional diagnosis : focal seizures with impaired awareness ?temporal lobe epilepsy

INVESTIGATIONS:-

ECG:-

CXR -PA VIEW:-

HEMOGRAM:-

Hb:-8.7g/dl

TLC:-9600 cells/cumm

NEUTROPHILS:-70%

LYMPHOCYTES:-20%

MONOCYTES:-08%

EOSINOPHILS:-03%

PCV:27.5 vol%

MCV:73.7fl

MCH:-23.3pg

MCHC:-31.6%

RBC:-3.73millions/cumm

PLATELETS:-3.92 lac/cumm

FBS:-85mg/dl

SEROLOGY:-negative

RFT:-

Urea:-36mg/dl

Creatinine:-0.8mg/dl

Na+:-134mEq/L

K+:-4.1mEq/L

Cl-:- 96mEq/L

LFT:-

Total bilirubin:-1.81mg/dl(0-1)

Direct bilirubin:-0.60mg:dl(0-0.2)

AST:-14IU/L(0-35)

ALT:-10IU/L(0-45)

ALP:-87IU/L(56-119)

Total proteins:-6.3g/dl(6.4-8.3)

Albumin:-3.6g/dl(3.2-4.6)

A/G:-1.37

MRI BRAIN:-

Impression:-diffuse cerebral atrophy

EEG:-

Normal

TREATMENT GIVEN:

1.T.levipil 500 mg PO/BD

2.Inj .OPTINEURON 1 AMP in 500 mlNS/ IV /OD

3.Inj . pantop 40 mg / IV / OD

4.Inj .thiamine 100 mg in 500ml NS/ IV / OD

Periventricular hyperintensities???????

https://psychscenehub.com/psychinsights/white-matter-hyperintensities-mri/

http://www.ajnr.org/content/ajnr/7/1/13.full.pdf

EXPECTED DISCHARGE SUMMARY:-