65 yr old female with involuntary movements of Lt upper limb

February  ,2023
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

Name : SANTOSH KUMAR .K ( Intern ) 

Roll Number : 62

I have 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 compliants
A 65 yr old female patient came to casualty with complaints of lt upper limb  since 1 day 
Cough since 4 days 
HOPI 
Pt was apparently asymptomatic  1 week ago then she developed generalised weakness , fell down from bed  and complaints of pain in the hip 
Involuntary movements of lt upper limb since 1 day to and fro 
No history of speech abnormalities , weakness in the upper limb and lower limb .
No H/o memory loss and abnormal posturing .
Complaints of cough since 4 days ,it is productive scanty sputum - white to yellow ,non blood stained and non foul smelling 
H/o inadequate controls of sugars from 4 months 
N/H/o vomiting ,sob,loose stools ,pain abdomen
K/c/o type 2 DM since 30 yrs on infusion since 10 yrs 
( Insulin - lispro 20-x-20 )
K/c/o HTN  from 20 yrs on T prolomet - xl 50 mg 
                                                T. Atenolol 25 mg po/ od at 10 am

K/c/o hypothyroidism  from 15 yrs on thyronorm 75 mcg
Previous  treatment history
Hospitalised 1 yr ago for UTI 
https://rishikoundinya.blogspot.com/2022/08/54-year-old-female-with-uncontrolled.html?m=1
H/o hysterectomy 30 yrs ago 
Personal history

DIET- mixed
Appetite: Normal
Bowel and bladder movements are regular
Sleep: adequate 
No  allergies
Chews tobacco 
Chews betel nut and betel leaf twice daily 

General examination
Pt is conscious , incoherent, cooperative
Pallor present
No 
      Icterus
      Cyanosis
       Clubing
       Lymphadenopathy
Edema present B/L pitting type extending up to knee
Vitals
         BP 110/70mmhg
         PR 76 BPM
         RR 18 cpm
         Spo2 98
Grbs. 315 mg/ dl
Systemic examination
       Respiratory examination
        BAE +ve and normal vesicular breath sound heard 
        No crepts heard 
      CVS examination
       S1S2 heard 
        No murmurs heard
        Abdomen examination
        Soft non tender
        No hepatomegaly and splenomegaly
CNS examination 
Higher mental functions intact
Conscious , coherent non cooperative 
Speech normal 
Motor system                  Rt.        Lt 
                       Tone. Ul.    N.          N
                                  Ll.     N.          N
                  
         Power                          Ul.     N.         N
                                               Ll.       N.         N
   Reflexes      B.     T.      S.      K.       A
              Rt.      1+.    1+.    _.      1+.   _ 
              Lt.      1+.     1+.    _.      1+.   _
Plantars. B/L flexors
No cerebellar and meningial signs 

Provisional diagnosis 
Hyperglycemia with hemiballismus K/C/o  type 2 DM with HTN since 20 yrs 
K/c/o hypothyroidism since 15 yrs 
K/c/o CKD since 2 yrs 
Diabetic nephropathy with recurrent UTI with iron deficiency anemia


Investigation 

Usg abdomen    
B/l  grade 1-2 RPD changes with raised echogenecity 
Lab investigation 



X ray pa view 

Ecg
Treatment
1  inj HAI 6 units /IV/ stat followed by insulin infusion 1 ml/ hr
2 IVF NS @ 75 ml/ hr
3 5 D @ 50 ml / hr 
4 check grbs hrly and infusion 
5 monitor vitals and inform sos 
6 NBM till further orders and I/O charting 

Fever chart


8/2/2023
Dr Aashitha Sr
Dr pradeep pg 3
Dr Vinay pg 3
Dr Narsimha pg 2
Dr Ajay pg 1
Dr prachethan pg 1
Dr k Santosh Kumar intern 
Dr jatin intern

ICU bed 4 
New case 
65/F

S
No fever spikes 
Stools passed 
Involuntary movements of Lt upper limb 
O
 Pt is c/c/ c
Bp 150/80 MMHG
Pr. 82 bpm
Grbs. 155 mg/ dl. 
Temp 98.2 F 
CVS S1S2 HEARD no murmurs
RS BAE + NVBS + 
P/A soft nontender 
CNS HMF intact
GCS. E4 V 5 M 6

A
Hyperglycemia with hemiballismus K/C/o type 2 DM with HTN since 20 yrs 
K/c/o hypothyroidism since 15 yrs 
K/c/o CKD since 2 yrs 
Diabetic nephropathy with recurrent UTI with iron deficiency anemia

P 

 inj HAI ( 1 ml + 39 ml NS ) @ 2 ml / hr ( it will be increased or decreased based on grbs values) 

 IVF NS @ 75 ml/ hr
   IVF 5 D. 50 ml/ hr

 hourly grbs monitoring and monitor vitals and inform sos 
 
T promolet Xl 50 mg po/od at 8 am
 
T thyronorm 75 mcg po/ od @ 7 am 

T tetabenazine 12.5 mgPo/ od

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