55 year old male with involuntary movements of neck and both upper limbs

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Case-

A 55 year old male came to opd with 
c/o involuntary movements of neck 
A/w right and left shoulders since 3 days
h/o fever since 4 days

Hopi:
Pt was apparently asymptomatic 1 year back and give h/o recurrent burning  sensations in retrosternal  region and epigastric region and on regular  medication   also gave h/o constipation  and taking medication regularly (Dulcolax)
He had h/o fever 4 days back not a/w nause, vomiting, cold, cough 
- h/o loss of appetite since 4 days
- h/o involuntary movements starting  with neck progressively involving to both shoulders (upper limb)
High frequency,low amplitude,absent during sleep, increased on stretching both hands, no difficulty in performing activities,

No h/o  any  weakness of both upper limb and lower limb, tingling sensation, numbness
Decreasing of neck movements on sleeping and on work  
No h/o movements  on resting, increasing  on extension of hands
Add decreased sleep since 4 days, pt was anxious about his condition

Past history-
No similar complaints in the past
h/o asthma since 10 years and on medication 
He is not a k/c/o DM type2 /HTN/Epilepsy/TB

O/E:
Pt is conscious,oriented to time,place,person
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
Decreased appetite  and irregular bowel movements 

Vitals :
Pt is c/c/c 
Temp- afebrile
Bp-140/100mmHg
Pr-96 bpm
RR-18 cpm
Spo2- 96% on RA
CVS-S1,S2 +
RS-BAE+ NVBS
P/A- soft,non tender
         BS+
CNS- HMF intact
   
Power     R        L
UL          5/5     5/5
LL          5/5     5/5

Reflexes-
     B   T    S   K   A   P
 R  2+ 2+  2+ 2+ 1+ withdraw
 L  2+ 2+  2+ 2+ 1+ withdraw


Provisional Diagnosis 

TREMORS  UNDER EVALUATION (? TARDIVE DYSKINESIA)

Investigations-
On 09-09-2021
Hemogram-
HB- 15.4
TLC- 9000
PLT- 2.50 lakh/cu.mm 
N- 45
L- 45
E- 04
M- 06
B- 00

RBS- 105
Ca- 10.0
Na+ 143
K+  4.0
Cl-  97

On 10-09-2021:-
Hemogram-
HB- 13.7
TLC- 5600
Plt- 2.3
PCV-  39.2
Malarial parasite- negative
CUE:
Albumin- nil
Sugars- nil
Pus cells- 2-4
Epithelial cells-  2-3
RFT:
Blood urea- 19
Sr.Creat - 1.1
Uric acid- 5.0
Ca- 9.5
Na- 142
K- 3.9
Cl- 97
P- 2.4
LFT:-
Tb- 0.74
DB- 0.17
SPOT- 49
SGPT-52
ALP- 121
TP- 6.5
Albumin- 3.54
A/G - 1.20

X ray-
MRI-
Treatment given-

11/09/2021
SOAP NOTES- A 55 year old male with involuntary movements of neck

Subjective-  cough with expectoriation
C/o disturbed sleep resolved with resolution of movements

Objective -
Pt is c/c/c 
Temp- afebrile
Bp-120/80mmHg
Pr-84 bpm
RR-18 cpm
Spo2- 98%
CVS-S1,S2 +
RS-BAE+ NVBS
P/A- soft,non tender
         BS+
CNS- HMF intact
   
Power     R        L
UL          5/5     5/5
LL          5/5     5/5

Reflexes-
     B   T    S   K   A   P
 R  2+ 2+  2+ 2+ 1+ withdrawl
 L  2+ 2+  2+ 2+ 1+ withdrawl

Assesment:-
TREMORS  UNDER EVALUATION (? TARDIVE DYSKINESIA)

Plan of care -
1) IV fluids - NS with 1amp of optineuron @7ml/hr  &RL

2) Tab.PCM  500 mg/PO/SOD

3) Tab.Cetrizine 5mg PO/SOS

4) Syp.Ascoril 10ml PO/SOS

5) Syp.Arystozyme 10ml PO/TID

6) Tab.Clonazepam  0.5mg PO/SOS

 


 

 

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