A 60 year old female came with uncontrolled abnormal movements lasting more than 30 minutes



This is an elog prepared with the de-identified health data collected after taking the informed consent of the patient and her attender reflecting an attempt at patient-centered approach to learning clinical medicine. 

The patient was brought is a 60 year old woman hailing from Nalgonda. She lives with her elder daughter's family and spends most of her time at home, managing the housework.

She was brought to the OPD by her daughter 3 days ago in an unconscious state, with uncontrolled abnormal movement of limbs lasting for more than 30 minutes.

HOPI

The patient was apparently asymptomatic 23 years ago when, due to a head injury she sustained during a fall a few years before, she began experiencing these episodes of "fits" or (uncontrolled abnormal movements of the limbs and loss of consciousness) with a frequency of 0-2 times/year. Patient has been on anticonvulsive medication since the past 23 years.

A typical episode begins with headache and dizziness, up-rolling of the eyes followed by loss of consciousness and uncontrolled involuntary movements of the arms and legs, clasping of the hands and deviation of the mouth to one side. Frothing and tongue bite was seen in the initial years. She usually regains consciousness 5-10 minutes later in a confused state, with no memory of the episode. There have been instances of falling to the floor when no one was around to help her. The precipitating factors for such episodes were emotional distress and/or lack of sleep. 

The current episode began in the morning time, when the patient was on an empty stomach and complained that she felt uneasy. She also had a right sided headache of dragging type, radiating to her neck. This was followed by up-rolling of the eyes, clasping of the hands, loss of consciousness, and involuntary movements of the limbs which did not subside even after 30 minutes. 


PAST HISTORY

There were several admissions to various hospitals in the past due to similar complaints. 
She has been taking anticonvulsant medication since 23 years. 
She underwent 3 cesarian sections in the past.
No history of diabetes mellitus, hypertension, tuberculosis, asthma or CKD.

FAMILY HISTORY

Not significant.

PERSONAL HISTORY

Patient consumes a mixed diet, has a normal appetite.
She get adequate sleep. 
No urinary symptoms.
She passes bowels every other day. 
No addictions.
Daily routine: she wakes up early in the morning at 4 am and manages the housework, eats two or three meals per day and goes to bed early by 7pm.

TREATMENT HISTORY

The patient has been taking anticonvulsants since the past 23 years. 

GENERAL EXAMINATION

Patient was conscious, coherent and slightly irritable at the time of examination. 
She has a moderate build, appears moderately nourished.
Pallor: Absent
Icterus: Absent
Clubbing: Absent
Cyanosis: Absent
Lymphadenopathy: Absent
Edema: Absent
 
         



VITALS

PR: 86 bpm, regular rhythm, normal volume, good character of the vessel wall, no radio-femoral delay.
BP: 100/60 mm of Hg, taken from the right arm in sitting position.
RR: 24 cpm, thoracoabdominal type of respiration.
Temperature: afebrile to touch.


SYSTEMIC EXAMINATION

CNS EXAMINATION


MOTOR SYSTEM:

Bulk: No wasting was observed.

Tone: Normal

Power grading: 
RUL: 4+; LUL: 4+
RLL: 4+; LLL: 4+

Reflexes:
  1. Biceps: normal 
  2. Triceps: 
  3. Knee jerk: reduced 
  4. Ankle jerk: 
  5. Plantar:




SENSORY SYSTEM:

Fine touch, crude touch, pain and temperature sensation and proprioception are intact.

CRANIAL NERVE EXAMINATION:
  1. Olfactory: decreased sense of smell
  2. Optic: visual acuity is decreased in both eyes (counting fingers: 1m)
  3. Oculomotor: intact
  4. Trochlear: intact
  5. Trigeminal: 
  6. Abducens: intact
  7. Facial: 
  8. Vestibulocochlear:
  9. Glossopharyngeal: 
  10. Vagus: 
  11. Spinal accessory: 
  12. Hypoglossal: 
SPEECH: Normal.

CEREBELLUM: 

CVS EXAMINATION

S1 and S2 heard. No murmurs were present.

RESIRATORY SYSTEM EXAMINATION

Trachea is central. Bilateral air entry is present. 
Normal vesicular breath sounds heard. No adventitious sounds heard.

PER ABDOMEN EXAMINATION

Soft, non tender abdomen. No organomegaly detected. 


PROVISIONAL DIAGNOSIS

This is a case of a 60 year old woman who came with episodes of uncontrolled abnormal movements of the limbs and loss of consciousness lasting for more than 30 minutes, preceded by headache suggestive of generalized tonic clonic seizures.


INVESTIGATIONS

The following investigations were performed:
MRI BRAIN:


ELECTROCARDIOGRAM:




BLOOD SUGARS:




GLYCATED HEMOGLOBIN:


HEMOGRAM:



LIVER FUNCTION TESTS:


BT, CT, PT & aPTT:

 


BLOOD GROUPING:


RENAL FUNCTION TESTS:


SERUM MAGNESIUM:


CARDIAC TROPONINS:



TREATMENT

STAT MEDICATION:

Inj. Lorazepam 2cc IV (Benzodiazepine)
Inj. Levipil 2gm IV (Levetiracetam, anti-epileptic)
Inj. Neomol 2gm IV (Paracetamol)

MEDICATIONS ADMINISTERED:

DAY1: Inj. Levetiracetam 1 gm IV, Inj. Optineuron (Vitamin B complex) 1amp IV, Inj. Ceftrioxone 2gm IV

DAY2: Inj. Levetiracetam 1hm IV,  Inj. Ceftrioxone, Tab. Ecosprin (Aspirin), Tab. Clopitab (clopidogrel, antiplatelet), Inj. Optineuron.

DAY3: Inj. Levipil, Inj. Ceftrioxone, Inj. Optineuron, Tab. Atorvastatin, Tab Ecosprin.

DAY4:  



 SUMMARY 

This is a case of a 60 year old woman who presented with active uncontrolled movements of limbs and loss of consciousness lasting more than 30minutes under treatment for Generalized tonic clonic seizures.


 

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