A 70 year old female came with as sudden involuntary movements

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I have been given this case 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.

A 70 year old female came to the OPD with 

CHIEF COMPLAINTS :

- Sudden involuntary movements since 5 pm yesterday

HISTORY OF PREENTING ILLNESS :

- The patient was apparently asymptomatic 2 days back.Some time after having food , she experienced SOB on lying in supine position.She was unable to speak suddenly. There was involuntary passage of urine. 

- H/o single  episode of vomiting non projectile, food as content in the night after which she felt better. 

- The patient did not have any such complaints the next day. Yesterday, the patient did not consume any food from morning till afternoon. Only intake of coconut water and ragi java at around 1pm.

- She was just lying and then suddenly she had involuntary movements of the right upper and lower limb at around 4 to 5' o clock associated with aura. She felt weak in those limbs and couldn't get up. She was conscious but her speech was incoherent. No frothing , no tongue bite. 

- Pt was taken to the nearby hospital in Ramanapet and symptomatic treatment was given after which she was referred to a higher centre. Her last memory was that of sitting in an auto and going to the hospital. 

- H/o burning micturition since 15 days 

- H/o fever 2-3 days back

PAST HISTORY :

- No similar complaints in the past 

- She is not a k/c/o HTN, DM, TB, bronchial asthma, epilepsy, CAD, CVA 

- H/o thorn prick to plantar aspect of both right and left foot 20 years back for which she went to a local hospital and some medication was taken. Then after few year it grew into a huge ulcer which is associated with hypoaesthesia.

Chemo/Radiation Exposure - No

No blood transfusion 

Surgical history - No

FAMILY HISTORY : Nil significant 

 

PERSONEL HISTORY :

She is a home maker

Diet - Mixed

Appetite - Normal  

Bowel and bladder - Normal

Allergies - No

Addictions - No

GENERAL EXAMINATION :

Temperature - 98.5 °F

Pulse - 70 beats/min

BP - 90/60 mmHg

RR - 26 cycles/min

GRBS - 342 mg%

SPO2 - 94 %

Pallor - No

Icterus - No

Clubbing - No

Cyanosis - No

Lymphadenopathy - No

SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard

RESPIRATORY SYSTEM :

Position of trachea - Central

No Dyspnoea , Wheeze

Breath Sounds - vesicular

ABDOMEN :

Shape - Scaphoid

 Tenderness

No palpable mass

Umbilicus inverted

Bowel sounds heard

CNS : 

Patient is Consious, Coherent well oriented to time place and surroundings 

GCS : E4V4M6

INVESTIGATIONS :

Investigations - 

PROVISIONAL DIAGNOSIS :

Seizures due to uncontrolled Sugars

TREATMENT :

INJ IV FLUIDS(NS/RL/DNS) @UO + 50ML/HR

INJ HUMAN INSULIN 40 U IN 39ML NS IV @6ML/HR INCREASE/DECREASE TO MAINTAIN GRBS< 200MG/DL

INJ KCL 2 AMP IN 500 ML NS/IV @4 HRS  

INJ OPTINEURON 1 AMP IN 100 ML NS/ IV OD 

INJ LEVIPRIL 1 MG /IV STAT 

INJ LORAZ 2 CC / IV STAT OR SOS

PROTEIN X POWDER 1 SPOON IN 100 ML MILK 8 th HOURLY 

GRBS MONITORING EVERY HOURLY 

BP/ PR/ TEMP EVERY 4 TH HOURLY