65yr old man case

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HOPI:-

      A 65yr old man , farmer by occupation came with complaints of  involuntary movements of bilateral upper and lower limbs lasting for about 3 to 5 minutes.

      Patient was apparently asymptomatic till morning and has done his daily activities without any fail. Then his attender noted him developing sudden onset of involuntary movements of bilateral upper and lower limbs which are tonic type lasting for 3 to 5 minutes. This activity is associated with uprolling of eye balls amd frothing. Post ictal confusion lasted for about 5minutes and he has no memory of that event. 

   No history of tongue bite, bowel amd bladder incontinence , loss of consciousness.

No h/o alcohol intake before seizure activity

  No history of shortness of breath, chest pain, fever, pedal edema, decreased urine output, blurring of vision. No history of Weakness of limbs, loss of sensations.

 No h/o loss of smell, deviation of mouth, slurring of speech., difficulty in breathing and swallowing.

   He became normal after the activity without any interventions or any medical help. They came to hospital after 2hrs of the event and no such similar activities are noted in between.

  *Past history:-

 - no similar complaints in the past.

-- not a k/c/o HTN, DM, TB, ASTHMA, CAD, CKD,EPILEPSY

-- no past surgical history

 * Personal history :-

       He takes a mixed diet with good appetite and regular bowel and bladder habits. He gets adequate sleep and is a chronic alcoholic  since 10 years drinking approximately 100ml toddy per day and chronic smoker since 5yrs 2beedis/day .

Family history:- not significant. No similar complaints in family.

General examination:-

    At the time of presentation patient was comfortably lying in his couch, conscious coherent , co operative and oriented to time ,place and person. There were no involuntary movements noted.

VITALS:-

TEMP - 98F

PULSE- 116bpm, regualr , normal in volume

BP -- 110/80mm of hg

RR -- 18 breaths per min

SPO2-- 99% at room air

GRBS -- 173mg/dl

        No sings of pallor, icterus , clubbing, cyanosis, koilonoichia, lymphadenopathy,edema.

CVS:- S1, S2 heard, normal, no murmurs

RS :- BAE+ , NVBS+, no added sounds

PER ABDOMEN :- soft, scaphoid,non tender,no organomegaly, no free fluid, all hernial orifices are normal, bowel sounds are heard. 

CNS:- 

  -HMF- intact

  - CRANIAL NERVES -- all cranial nerves are normal

  -MOTOR SYSTEM              RT           LT

     Bulk --                         normal        normal   

     Tone --         UL         normal       normal

                          LL          normal        normal

      Power         UL            5/5              5/5

                          LL             5/5               5/5

     Reflexes     

                  Biceps             +                  +

                  Triceps           +                 +

                   Knee               ++            ++

                  Ankle              +                 +

                  Plantar           normal      normal

          

  - SENSORY SYSTEM 

             Sensation, Vibration , Proprioception are intact

 - CEREBELLUM :- intact., no abnormality

- GAIT :-

            The patient had gross left genu valgum since his childhood. They deny any history of trauma, swelling or pain in both knees.

   

INVESTIGATIONS:-

 Depending on his condition the following investigations have been done.

Day 1:-

1.HAEMOGRAM:-

    Hb- 11.1gm/dl,TLC:- 9,100cells/cu.mm, RBC- 3.83million/cu.mm PLATLETS:-1.91Lakhs/cu.mm

SMear showed normocytic normochromic blood picture.

 2. CUE:-

     Clear, pale yellow, straw coloured urine with specific gravity 1.010., with ALBUMIM- TRACES, SUGARS - NIL, BILE SALTS-NIL, PUS CELLS- 2-4,NIL RBC.

3.RBS-- 149mg/dl

4.SERUM POTASSIUM:- 3.7mmol/litre

5.MRI BRAIN

LFT

RFT:-

CHEST XRAY

    

DAY 2

OPHTHAL REFERRAL:- for changes of papilloedema. And optic neuritis because that might be a focus for seizure activity and is a finding which cannot be seen in MRI BRAIN

DAY 3:-

1.FASTING LIPID PROFILE

2.THYROID PROFILE

3. 2D ECHO

 Under 3days of  observation there was no new activity of involuntary movements and no fresh complaints from patient.

*TREATMENT GIVEN:-

1.INJ.OPTINEURON 1ampoule in 100ml NS IV BD

2.TAB.LEVIPIL 500MG BD PO

3. TAB.PANTOP 40mg OD PO

4. TAB.ULTRACET  BD PO

5.TAB.MVT OD PO

Pt. Got discharged and on discharge the following medications are advised

1.TAB.LEVIPIL 250mg 4days treatment

    Day 1 and 2  250mg BD

    Day 3 and 4  250mg OD and stop

2.TAB. SODIUM VALPROATE 300mg OD

3.TAB PANTOP 40mg OD x 5days

4 TAB.ULTRACET BD x 5days

5.TAB MULTIVITAMIN OD x 10days