A 35yr old female with Involuntary movement's of Right upper & lower limb

SHORT CASE-1

A 35yr old female patient who's a bank employee by occupation came to casuality with chief complaints of involuntary movement's of right upperlimb & lowerlimb since afternoon 2pm.

History of presenting illness:-
Patient was apparently asymptomatic till today morning, when she developed mild weakness of her right upperlimb & lowerlimb for which she went to local hospital & got few medications & later it subsided, she then attended her bank work where at around 2pm she had sudden involuntary movement's of right upperlimb & right lowerlimb which lasted for 2 to 3 minute's, She had around 5 similar episodes with a time gap of 10minutes.

They're associated with post ictal drowsiness & are not associated with involuntary micturition/defaecation/uprolling of eyeballs/ Tongue bite/deviation of mouth/automatic behavior like running, walking about,Violent behavior.. Etc. 

She had an similar episode in casuality & she's  having post ictal confusion & drowsiness . 
From the next day she's drowsy & complained of headache & vomitings. 

No h/O palpitations/syncopal attacks/facial deviation/dysphagia/chest pain/ orthopnoea /PND/Neck pain/Projectile vomiting/

Past history:-
No h/O similar complaints in past
Not a k/c/O Hypertension/Diabetes mellitus/ Asthma/epilepsy/TB/CAD/Migraine/Thyroid disorders/psychiatric disorders. 

Drug history:-
No known drug allergies/No history of any chronic medications/Oral contraceptive pills intake. 

Family history:-
No h/O similar complaints in family members. 

Personal history:-
Sleep- Adequate
Appetite- normal
Bowel & bladder - regular
No addictions. 

Summary at the end of history:-
A 35yr old female who's a bank employee came with complaints of repeated episode's of involuntary movement's of right upperlimb & right lowerlimb since afternoon which are associated with post ictal confusion & drowsiness & later she had headache & vomitings. 

Differential Diagnosis:-
Complex partial seizures secondary to CVA/Cerebral veinous thrombosis. 

General examination :-
Pt is drowsy
No pallor/icterus/cyanosis/ clubbing Lymphadenopathy/ edema/
Temperature - Afebrile 
Pulse rate -90 beats per minute ,regular, normal volume ,vessel wall normal ,no radio-radial or radio femoral delay, All peripheral pulses felt. 

Bp- 110/70mmhg in both arm's supine position
Respiratory rate- 20cpm
Grbs - 109mgdl

SYSTEMIC EXAMINATION:-

Central nervous system-
Patient is drowsy.
GCS - E3V3M3
Pupils- Normal size & reactive to light. 
Cranial nerves- corneal reflex +nt
No fixed gaze seen, patient is able to look at all sides on repeated verbal commands. 
Vestibulooccular reflex intact. 
Motor system:-

BULK- Appears normal on both sides

TONE -                      Right                 Left
             
       Upper limb-   Normal               Normal

       Lower limb-   Normal               Normal

POWER - couldn't be tested. But the patient is moving all her limbs on bed. 

                           Right                  Left 

Reflexes-     

     Biceps.          +                          +

   Triceps.          +                           +

Supinator.         +                           +

        Knee.          -                            -

      Ankle.           -                            -

Superficial reflexes 

Corneal.           +                             +

Conjunctival.   +                             +

Plantars.         Extensor.                Extensor


Sensory system:-
Moving her body to Deep pain & crude touch in all areas of body. 

Anterior Spino thalamic Tract:-

Crude touch:    +                         +

Lateral Spino thalamic Tract:-

Pain.                  +                          +

Temperature.   Cannot be examined

Posterior column : cannot be examined 

Fine touch.          -

Vibration.            - 

Joint position.    -

Rombergs.          -

Cortical : Cannot be elicited 

Two point discrimination    -

Tactile localization.             -

Stereognosis.                       -

Graphesthesia.                    -

Gait : cannot be examined 


Sign's of meningeal irritation:-
No neck stiffness .
Brudzinski sign absent
No kernigs sign

Cardiovascular system:-
Apical Impulse felt in left 5th ICS,
No visible pulsations in neck
No parasternal heave or precordial bulge felt
Both heart sounds S1S2 heard
No murmers heard. 


Respiratory system:-
Bilateral air entry present
NVBS, No added sounds heard. 

Provisional diagnosis:-
Acute complex partial seizures of Tonic clonic variety involving Right upperlimb & Right lowerlimb secondary to Cerebrovascular accident/Cerebral venous thrombosis. 

Investigations:-
Hemogram-
Hb- 12gm/dl
Tlc- 4,700cells/cu mm
Plt- 3.4lakh/cu mm

 Rft: 
 urea- 10mg/dl
Creatinine- 0.9mg/dl
 Sodium-139mEq/l
 Potassium-4.1mEq/l
 Chloride-99mEq/l

Lft:
Total bilirubin-1.28mg/dl
 Direct bilirubin-0.52mg/dl
 SGOT- 69 IU/L
 SGPT-12IU/L
 Alkaline phosphate- 113IU/L
 Total proteins - 7.5gm/dl
 Albumin-3.7gm/dl      

Esr- 18mm   
CUE- No pus cells/rbc/proteinuria
Fundoscopy:- Normal. 


Loss of flow void in Superior saggital sinus region. 





TREATMENT:-
1.Inj Levetericetam 1gm/Iv/Stat followed by 
Inj.Levetericetam 500mg/Iv/Bd
2.Inj pantoprazole 40mg/iv/od
3.Inj.mannitol/100ml/Bd
4.Ryles tube insertion & feeding. 
5.Temp/pr/Bp/SpO2 monitoring
6.Inform SOS, if seizure reccurs. 


Here's the Link to video of her seizures. 


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