46YR OLD FEMALE WITH INVOLUNTARY MOVEMENTS OF UPPER AND LOWER LIMBS

January 05, 2023

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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 COMPLAINTS:

Patient was brought to the hospital with complaint of 2 episodes of involuntary movements of both upper and lower limbs on 3/1/2023

HISTORY OF PRESENTING ILLNESS:

Patient developed involuntary movements of limbs on3/1/2023 5:00am episode lasted for 3 to 4 mins

She developed another episode after 1hr

She developed similar episodes at hospital

Patient was apparently asymptomatic 13yrs ago then she complained of generalized weakness and low backache on investigation she found to be having higher serum creatinine levels and is on conservative treatment

Since then she is on routine followup with hemogram and serum creatinine levels,and her baseline creatinine levels were 3.2mg/dL.

In June 2022, she developed fever and cough associated with shortness of breathe . On CT chest peripheral ground glass opacities and septal thickening were noted

later after few days, she developed swelling of both lower limbs upto ankles

Then she underwent dialysis for the first time through right IJV line, for 4 hours and was on conservative management for 2-3months.

3 months later, she developed fluid filled blebs over the fingers of hand

she also had eroding and distorted nails and hyperpigmented macules over the face, and itching over the palms, and low grade fever associated with loss of apetite and alopecia, she also developed ulcers on palms and finger tips associated with burning sensation

she was investigated for ANA profile . Positive for Anti Ro 52 and SSA/Ro 60++, and SSB/La+.

In the view of persistent low Hb-5-6 g/dl bone marrow aspiration was done to evaluate anemia

IMPRESSION : peripheral anemia with cellular marrow

Erythroid hyperplasia with dual morphology and increased iron stores

Plasma cells 02%

She was put on Mycophenolate Mofetil 360mg

Hydroxychoroquine, omnicortil

In November she developed cough since 1 week,with whitish color sputum, mucoid in consistency and moderate in amount and non blood stained and non foul smelling

and bilateral swelling of lower limbs till knee,not associated with any redness or trauma,and decreased urine output for 2 days,

and Shortness of breath MMRC grade 3, and loss of apetite, no abdominal distension, constipation, diarrhoea, facial puffiness, headache and seizure activity at that time,

and she was diagnosed as? Antisynthetase syndrome

withCLD secondary to autoimmune hepatitis with hypoalbuminemia

along with acute exacerbation of ILD,and recurrent anemia.

In December,in view of further increase in SOB, and abdominal distension she was taken to second session dialysis, antibody profile was repeated

and bronchoalveolar lavage was performed and was found to be having an infective etiology and mucus plugs in the airways.

On radiograph of chest, she was found to be having left lower lobe consolidation, and PET CT was advised and was done,and they suspected Tuberculosis for which she was on ATT

IMPRESSION ON PET CT: PET CT shows left lung consolidation, mediastinal nodes, minimal pleural effusion, spleenomegaly, diffusely thickened peritoneum

CURRENT SITUATION:

she developed sudden involuntary movements of upper and lower limbs on 3rd of january at 5 am

Similar episode was repeat at around 6 am

At hospital similar episodes occurred around 8 am

Recurrent episodes occurred and each episode lasted for 2mins

In the view of recurrent seizures CT brain was done

Inj lorazepam was given,

Later levitracetam

and then sodium valproate given as her seizures were not controlled.

Later she had continuous episode of seizures lasting for more than 45 min, then she was sedated with IV MIDAZOLAM and intubated.

General examination:

Patient is sedated