A 23 year old presented with involuntary abnormal movements of both upper and lower limbs.

13 Dec 2021

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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.This is an a 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.

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.

Maheshwari Jagathkari

Roll no. 57

A 23 year old presented with chief complaints of involuntary, irregular,rapid jerky movements of both upper and lower limbs since the age of 5 years

HOPI:

Patient was apparently asymptomatic before 5  years of age

When she was born in the year 1998 which was a normal vaginal delivery 

Cried immediately after birth, no H/O antenatal or natal complications

H/O swallowing of amniotic fluid.

H/O delayed milestones, anger, anxiety issues 

At the age of 3 years

C/O inability to walk for a period of 15-20 days with fever

Examination showed loss of deep tendor reflexes 

Then CT examination done which was normal 

EEG abnormal stage 2 sleep 

Treatment- started on valproate and regular follow up monthly done 

At the age of 7 years 

Patient continued to have similar episodes of rapid jerky movements during sleep which were preceded by arousal from sleep, more during morning 

Episodes occured few times  during cycling, when she stands after pronglonged sitting postion followed by leg pains.

Patient aware of these episodes beforehand.

At the age of 13 years 

Similar episodes

EEG done which was normal

Started on 

Tab. Tetrabenezene 25 mg 1/2 tab every night 

Tab. Valproate 300 mg BD 

Tab. Clonazepam 0.5 mg OD 

At the age of 16 years

Vit D deficiency 4.21

Started on VIT D capsules - 1 capsule a week for 6 months 

MRI done -Normal study 

Patient continued to have similar episodes with H/O injuries due to hitting of the limbs to the surroundings

At the age of 19 years 

She was started on ayurvedic medicine along with tetrabenezene, clonazepam for 5-6 months 

At the age of 20 years 

She visited a hospital with the same complaints 

Started on Tab.Haloperidol 0.5 mg BD

Continued valproate and clonazepam 

At the age of 21 years 

Started on Tab. Oxcarbamazepine 

Video EEG done -episodes in favour of paroxysmal hypnagogic choreoathetosis.

Stopped medication since 2 years 

At the age of 23 years

Since past 2 months, patient is having increased frequency of episodes more during night times even on slight disturbances during sleep 3-4/ hr lasting for less than a minute along with lower limb joint pains.

H/O anger issues along with depressed mood since 2 months.

Each episode has abrupt onset which lasts for a period of 3-5 min which are rapid,  jerky, involuntary movements of both upper and lower limbs with a frequency of 1 episode for ever 1-2 hrs with sleep disturbances.

H/O recurrent upper throat infections  

H/O itchy and painful skin  lesions over the buttocks and both the limbs since 1 month. 

Opthalmologic examination showed no KF rings.

Past history 

Not a known case of diabetes, hypertension, TB, asthma, CAD 

Personal history

Diet - Mixed 

Appetite - Normal 

Bowel and bladder - Regular 

Sleep - disturbed 

No addictions

No known drug allergies 

General examination 

Patient is conscious, coherent, cooperative, moderately built and nourished.

No pallor 

No icterus

No clubbing

No koilonychia

No lymphadenopathy 

No edema 

Black discoloration of skin over all the joints is noted 

Vitals 

BP 120/80

PR 106 bpm

RR 16 

Systemic examination 

CVS: S1 S2 +

RS:BAE+, NVBS+

P/A: soft, non tender

CNS:

Concious 

Speech:normal 

No neck stiffness

Cranial nerves, motor system, sensory system : NAD 

Investigations: 

Provisional diagnosis

? Benign hereditary chorea 

Adjustment disorder due to movement disorder 

Upper respiratory tract infection 

Ulcers secondary to ?folliculitis with trauma 

Treatment 

Tab. Tetrabenezene 12.5 mg BD 

Tab.Augumentin 625 mg OD 

Salt water gargles 

Momate f cream for local application BD