60M with involuntary movements of B/L UL and LL since 4hours and deviation of angle of mouth

Chief complaints: 
C/o involuntary movements of B/L UL and LL since 4 hours.

History of presenting illness: 
Patient was apparently asymptomatic 4hours ago then he developed involuntary movements in the B/L UL and LL since 4 hours sudden onset,involuntary,generalized tonic,clonic movements lasting for 2 to 5 minutes. Such episodes for 6 to 8 times initially in the left UL and LL then in the B/L UL and LL followed by loss of consciousness for 5 minutes then patient regained consciousness.
 H/O unrolling of eyes,clenching of teeth. N/H/O involuntary micturition and defecation,tongue bite, frothing.
No H/O fever,cough,vomiting,loose stools,pain Abdomen, giddiness. 
N/H/O weakness of B/L UL and LL . H/O deviation of angle of mouth.

Past history: 
K/C/O CVA since 1year-left hemiplegia- not on any medication.
K/C/O Hypertension since 1 year - not on any medication. 
Not known case of DM,asthma,TB,thyroid abnormalities,CAD,Epilepsy.

Family history: 
No significant family history.

Personal history: 
Diet: mixed
Appetite: normal
Sleep: adequate 
Bowel and bladder : regular
Addictions: Patient was an alcoholic and smoker 25years back. He is not drinking or smoking since 25years.

Daily rotinue: Patient wakes up at 5am and goes for a walk then freshens up and has breakfast and tea at 7am then watched T.V and rests for a while.  Has his lunch around 1 to 2pm then talks to neighbour's and roams around. In the evening he plays with his grandchildren and has dinner by 7pm and sleeps by 8pm.

General examination: patient is conscious,coherent,cooperative, moderately built and nourished.


Pallor: absent





Icterus :absent 

Cyanosis: absent 

Clubbing:absent 



Lymphadenopathy: absent 

Edema: absent 

Vitals:

BP:90/50mm Hg

Temperature:99.2F

Respiratory rate: 18cpm

Heart rate:82bpm


Systemic examination:

CNS: 

1. HIGHER MENTAL FUNCTIONS:

Conscious, coherent and Cooperative 

Appearance and behaviour:Emotionally stable 

Recent, immediate ,remote memory intact 

Speech : comprehension normal, fluency normal ,No repeatitions .

Right handed individual .


2. CRANIAL NERVE EXAMINATION: 

*Olfactory: Normal

*Optic nerve : visual acuity :

Pupil:  pupils reactive.

*3,4,6 : normal , ocular motility is present in all directions.

*Trigeminal : normal sensory and motor 

* Facial nerve : forehead wrinkles present. Able to close eyes, able to blow cheeks.

* 8th nerve : normal hearing,nystagmus absent 

* 9 and 10 nerves: normal

*11th nerve : SCM, trapezius : contraction 

*12 th nerve : no deviation of tongue, no fasiculations.


MOTOR EXAMINATION :

Bulk: normal 


Tone :           Right                     Left

Upper limb    Normal               Increased

Lower limb    Normal               Increased


Power:          Right                      Left 

Upper limb     5/5                      5/5

 Lower limb    5/5                         5/5


Reflexes : Right            Left 

Corneal present          present 

Conjunctival present   present 

 Deep reflexes  

Biceps          2 +               2+

Triceps        1 +                 1 +

Supinator     -                     -

Knee              1+                 1+

Ankle             -                     -

Plantar         extension      extension


SENSORY FUNCTIONS 

SPINOTHALAMIC TRACT 

Pain, temperature, pressure- intact in all limbs 

Posterior column :Fine touch,vibration, proprioception are intact

CEREBELLAR FUNCTIONS : 

Titubation: absent 

Nystagmus : absent 

Dysmetria : absent 

Dysdiadochokinesia : absent 

Intension tremor : absent 

No signs of cerebellar dysfunction.


CVS : S1 S2 ++ no murmurs heard. No raised JVP


RESPIRATORY SYSTEM: Normal vesicular breath sounds heard.


ABDOMEN: Soft, non tender.


Investigations: 

ECG: 




CXR:
 
CUE : Pus cells- plenty 

Provisional diagnosis 

Recurrent CVA with GTCS with hypertension.

Treatment: 

1. Inj optineuron 1amp in 100ml NS

2. Inj Levepil 1gm IV/BD 







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