70year old male with involuntary movements in left upper and lower limb

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Case presentation:

A 70year old male patient who is a farmer by occupation came with chief complaints of involuntary movements in the left upper and lower limb from two days.

HOPI:

Patient was apparently asymptomatic two days back then developed involuntary movements in left upper and lower limb.the movements were seen for every 5 to 10mins .

H/o frothing, up rolling of eyes and drowsiness present 

H/o post ictal confusion present 

H/o generalised pitting type of edema from one week.

No H/o loss of consciousness ,vomitings,headache,trauma

No h/o difficulty of breathing and fever.

PAST HISTORY:

K/C/O CVA left sided hemiplegia two years back (april2018) - middle cerebral infarct seen

K/C/O ? Acute motor axonal neuropathy variant of GBS , LMN type of momoparesis of left upper limb 2years back.

No h/o HTN DM TB asthma cardiac abnormalities 

H/o surgery ( unknown - reports are not available ) for acid ingestion 6years back.

H/o similar episodes of involuntary movements in left upper and lower limb 20 and 45days back resolved spontaneously.

PERSONAL HISTORY:

normal appetite 

Adequate sleep 

Normal bowel and bladder movements 

Addictions - smoker from 45yrs 

                     Alcoholic from 45yrs

GENERAL EXAMINATION 

Patient is conscious coherent and irritable 

Moderately built and moderately nourished

Pallor present 

No icterus clubbing cyanosis lymphadenopathy 

Generalised  pitting type of edema present

SYSTEMIC EXAMINATION 

CNS : not oriented

                                     Rt              Lt

Bulk                            N                N 

Tone         UL             N                Increased 

                  LL              N              Increased 

Power       UL             N               Not elicitable

                  LL             4                 3

Reflexes  biceps         -                 1+

                Triceps       -                  1+

                Supinator    -                  -

                 Knee          -                   -

                  Ankle        -                   -

                  Plantar      -                   Up going 

CVS S1 S2 heard no murmurs

GIT no organomegaly non tender 

RS BAE Present coarse crepts present 

INVESTIGATIONS:

18/11/20 chest xray

20/11/20 chest xray

HRCT. CHEST REPORT

DIAGNOSIS:

CHRONIC INFARCT IN RT MCA TERRITORY WITH GLIOSIS

LOBAR CONSOLIDATION RT LOWER LOBE

RECURRENT HYPOGLYCAEMIC EPISODES DUE TO SEPSIS

ALTERED SENSORIUM SECONDARY TO ?SEIZURES ?SEPTIC ENCEPHALOPATHY 

TREATMENT:

IVF - URINE OUTPUT PLUS 30ML

INJ LEVIPIL 500MG IV BD

INJ PAN 40MG IV OD

INJ ZOFER 4MG IV SOS

INJ PIPTAZ 3.375GMIV QID

INJ METROGYL 100Ml IV QID

INJ OPTINEURON 1AMP IN 100ML NS IV OD

TAB PCM 650MG SOS

INJ LASIX 40MG IV BD

SYP LACTULOSE 15ML BD

2SCOOPS PROTEIN POWDER IN 100ML MILK TID

SALBUTAMOL NEBULISATION 8TH HRLY

MONITOR VITALS 

HEAD END ELEVATION