30 year old female with involuntary movements

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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 diagnosis and treatment plan.

Chief complaints : 

A 30 year old female with c/o involuntary movements (jerky movements) in b/l upper limbs since 2 days  

HOPI: 

Patient was apparently asymptomatic 2 days back then she developed involuntary movements of upper limbs not associated with loss of consciousness

no tongue biting, no involuntary micturition during episodes 

Each episode lasting for 3-4 sec 

Day -1(11-10-2022)- 1 episode 

Day -2(12-10-2022)- 2 episodes 

Day -3(13-10-2022)- 6-8 episodes 

Past history;

Not a k/c/o DM, asthma, epilepsy, CAD, CVA 

K/c/o HTN 11years back during her 1st pregnancy used medication for 6 months and then stopped 

No significant family history 

Personal history; 

Appetite : normal 

Diet : mixed 

Bowel and bladder habits : regular 

Habits : none 

Allergies: none 

General examination ;

Patient is conscious, coherent, cooperative 

Well oriented to time , place and person 

No pallor, icterus, cyanosis, Clubbing, lymphadenopathy, edema 

Vitals:

Temperature; 98.6•f 

BP; 140/90mm of Hg

PR; 105bpm

Spo2;99%

 

                     

Systemic examination:

CVS: s1,s2 heard 

        No murmurs 

RS; B/L normal vesicular breath sounds heard 

Per Abdomen; soft , non tender 

           Bowel sounds present 

CNS;

Higher functions:

Right handed 

Conscious 

Oriented to time ,place and person 

Memory: recent- present 

              Immediate: present 

              Remote: present 

Speech:

           Normal 

No delusions or hallucinations 

Cranial nerve examination:

I- Olfactory nerve-  sense of smell present 

II- Optic nerve- direct and indirect light reflex present

III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis

V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.

VII- Facial nerve- face is symmetrical, able to do forehead wrinkling 

VIII- Vestibulocochlear nerve- no hearing loss

IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised

XI- Accessory nerve- sternocleidomastoid contraction present

XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue

Spinomotor; 

                                Right                        Left 

Bulk:  U/L  

                   arm :  normal                 Normal 

            Forearm: normal                 Normal 

           L/L  

                 thigh: normal                  Normal 

                   Leg: normal                Normal 

Tone:        U/L:   Normal               Normal 

                  L/L:   Normal               Normal 

Power: 

         U/L

                Hand :    5/5                     5/5 

               Elbow:    5/5                     5/5

          Shoulder :   5/5                     5/5

        L/L

                 Ankle:   5/5                     5/5 

                 Knee:    5/5                     5/5

                   Hip:     5/5                     5/5 

Reflexes:

          Biceps:        +                             +

          Triceps:        +                            +

         Supinator:     +                             +

         Knee:             +                             +

         Ankle:           +                              +

         Plantar:    Flexion                  Flexion

        

Sensory system ; 

           

         crude touch :       present              present

           

          fine touch  :        Present              present             

             pain         :       Present               present

            vibration :        Present              present

        temperature :       Present             present 

       stereognosis:      Present              present

2 pt discrimination:   present               present

    graphaesthesia:    Present              present 

Coordination; present 

Gait: normal 

Investigations: 

Hemogram: 

       

        On 13-10-2022

      

        On 14-10-2022

LFT: 

Serum calcium:

      

Serum creatinine: 

Serum electrolytes: 

Serum magnesium 

Serum urea: 

Serology ; negative 

EEG:

ECG:

2D ECHO: 

Chest X -ray : 

Provisional diagnosis:

 

?myoclonal jerks 

? Focal seizures 

Treatment:

1) Inj sodium valproate  2gm in 100ml NS Iv stat over 20 min 

2) Inj sodium valproate 500mg IV BD 

3) Inj midazolam 2cc IV sos 

4) Inj optineuron 1 amp in 100ml NS Iv OD 

5) Inj PAN 40mg IV OD BBF

6) Tab Dolo 650mg po sos