A 75 year old woman came with chief complaints of Involuntary movement of hands and head

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

A 75 year old woman came with chief complaints of 

Involuntary movement of hands and head bobbing since 7AM 22/2/22

Burning micturition since 1 week 

History of presenting illness: 

Patient was apparently asymptomatic 10 days back and then developed fever which was insidious in onset, continuous and subsided with medication. 

Involuntary movement of hands and bobbing of head at frequent intervals seen. 

Frequent episodes of burning micturition which subsided on medication present. This time inspite of usage of same medication she isn’t feeling better. 

There was sudden onset of shivering since morning and burning micturition since one week associated with chills,Right flank pain present, increased frequency of micturition at night. 

Patient is conscious but only responding to some questions, and giving only monosyllable responses. 

She was active till today morning and performed her routine activities and maintained hygiene. She couldn’t cook for herself since 5-6 months as she couldn’t light the stove. 

History of fall 13 years back, she injured her knee. History of massage of knee after injury,non healing of injury and discharge from the wound present. Skin grafting done sit to non healing of wound.

On check up for fall, she was diagnosed with Diabetes mellitus and Hypertension and is on regular medication for it (Tab. METFORMIN 500mg and Tab. MET XL) 

History of fall 10years back and fractured her wrist at that time. 

Using medication (Tab. ROSUVASTATIN,CLOPIDOGREL&ASPIRIN combination) for heart problem. On enquiry about the heart problem, the patient’s attender said that the patient complained of weakness so was taken to a doctor who said, there is narrowing of vessels and put her on the above medication. 

Past history: 

Was diagnosed with Hypertension and Diabetes mellitus 13 years back and is on regular medication for it. 

Drug history: 

Metformin 500mg

Cefixime and OFLOXACIN

Met XL

NODOSIS 

Paracetamol,Aceclofenac and Serratiopeptidase 

ROSUVASTATIN,CLOPIDOGREL&ASPIRIN

Personal history: 

Diet: mixed 

Appetite: decreased 

Sleep: disturbed 

Bowel and bladder movement: burning micturition +, bowel movements normal 

Addictions: none 

General examination: 

Temperature: 97.4°C 

PR: 88bpm

BP: 130/70

SpO2: 98%

GRBS: 155mg/dl

CNS Examination: 

Patient is conscious, oriented to time, person 

Speech - normal 

Reflexes -

        B. T. S. K. A. P

Rt. + + +. +. +. + 

Lt. + + +. +. +. +

            

       

             Rt. Lt

Tone 

UL N. N

LL. N. N

Power rt. Lt

UL. -4/5. -4/5

LL. -4/5. -4/5

Rombergs positive 

Proprioception- lost

Cerebellar signs-

Tandem walking - impaired

No nystagmus 

UL and LL coordination impaired

Investigations: 

 Hemogram: 

Hb: 7.6

TLC: 13,600

N: 90

L: 05

Imp: Normocytic hypochromic anemia with neutrophil leukocytosis

USG ABDOMEN: 

Imp: Bilateral RPD changes seen in kidneys. 

Ophthalmology referral:

I/V/O raised intracranial pressure. 

Imp: optic disc not visualised due to dense lenticular opacities

ECG: shows sinus rhythm with left ventricular hypertrophy. (Lyon Sokolow criteria) 

Diagnosis: Myoclonic jerks secondary to PCA STROKE