33 F with DRUG induced Dystonia
33 F with DYSTONIA? DRUG INDUCED
July 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.
This is 38 year old female .homemaker by occupation was brought to casualty with a c/o -
C/o paroxysmal involuntary opening of mouth and involuntary deviation of head and neck to both sides on and off from yesterday (10:30 am.on 03/05/2023)
HOPI
Patient was apparently asymptomatic till yesterday morning. Suddenly she developed paroxysmal involuntary opening of mouth and involuntary deviation of head and neck to both sides on and off
No H/o weakness of limbs
No H/o fever
No H/o loose stools
Patient underwent TAH +BSO 3days back(1/07/2023)(indication-anterior submural fibroid)
Past H/o
Similar complaints 15 months back after 2 nd baby delivery by LSCS
Is a N/k/c/o HTN,DM,CAD,Epilepsy, asthma
Underwent 2 previous LSCS(in 2020 and 2022)
FAMILY HISTORY
not significant
PERSONAL HISTORY
mixed diet
Normal appetite
Regular Bowel and Bladder movements
Sleep -disturbed (she had a elder brother who died in RTA 5 years back from then she is having sleep disturbance.
No allergies
addictions -
after his brother death she started consuming 2 glass of toddy daily
MENSTRUAL HISTORY
Age of menarche-13 yr
Regular cycle for 30 days till the birth of 2nd child then she is having menorrhagia and was diagnosed with anterior submural fibroid
OBSTETRIC HISTORY
She got married at the age of 28 yr in 2019
1st child in 2020
2nd child in 2022
ON EXAMINATION
temp-98.2f
Pulse rate -126 bpm
RR-16 cpm
BP-110/70mm of Hg
Spo2-96
GRBS-155 MG/DL
SYSTAMIC EXAMINATION
CVS-S1,S2+ ,NO MURMURS
RESPIRATORY SYSTEM-BAE+,NVBS heard
Per abdomen-tenderness present over the transverse scar
CNS-
B/L pupils reacting to light mid dilated
Tone in all four limbs normal
Power - RT LT
U/L 4/5 4/5
L/L 4/5 4/5
REFLEXES- B T S K A P
Rt ++ ++ ++ ++ - increased
Lt ++ ++ ++ ++ - increased
CRANIAL NERVES EXAMINATION
OLFACTORY-INTACT
OPTIC NERVE-VISION NORMAL
(3,4 AND 6) NERVE-PUPILLARY LIGHT REFLEX PRESENT,EXTRA OCCULAR MUSCKES INTACT
TRIGEMINAL NERVE-FACIAL SENSATION IS INTACT
FACIAL NERVE-FACIAL MUSCLES INTACT
VESTIBULO COCHLEAR-HEARING AND BALANCE PRESENT
IX NERVE-TASTE SENSATION PRESENT
X NERVE-NO DIFFICULTY IN SWALLOWING
XI NERVE-SHRUGGING OF SHOULDERS IS PRESENT
XII NERVE-NO DEVIATION OF TONGUE
DAILY ROUTINE
she wake up early in the morning at 5:30 Am cleans house and does household work then she have a cup of tea at 6:30 am
Eats rice with curry at 10:30am and does house hold work and take some rest in afternoon and then 1 cup of tea at 4:00 pm
Dinner at 7:30 ,and then she goes to bed
PROVISIONAL DIAGNOSIS
P2L2 WITH 2 PREVIOUS LSCS WITH TAH WITH BSO UNDER SPINAL ANASTHESIA PID -3 WITH CEVICAL DYSTONIA?DRUG INDUCED
INVESTIGATIONS
Hemogram
RBS
Sr creatinine
Sr calcium
Serum electrolytes
On 4/07/2023
0n 5/07/2023
CUE
Thyroid profile
Chest x-ray
ECG
TREATMENT
Inj DIPHENHYDRAMINE 25 mg iv Stat SOS
Vitals monitoring
Ophthalmology referral
I/v/o -mid dilated pupil and raised ICT features?
Review-no features of raised ICT noted in both eyes
Follow up
05/07/2023
C/O : involuntary opening of mouth and deviation of head to one side- 2 episodes yesterday at 12.00 pm and 7.30 pm
ON EXAMINATION:
PATIENT IS C/C/C
TEMP: 98.2 F
BP:130/70 mmHg
PR:72 BPM
RR: 16CPM
GRBS @ 8 AM : 99 MG/DL
CVS:S1,S2 HEARD ,NO MURMURS
RS:BAE+,NVBS, NO ADDED SOUNDS
P/A: SOFT, TENDERNESS OVER TRANSVERSE SCAR PRESENT
CNS:
B/L PUPILS ARE REACTING TO LIGHT
TONE NORMAL IN ALL LIMBS
POWER
UL: 4/5 (rt) ,4/5 (Lt)
LL: 4/5 ( rt),4/5(Lt)
Treatment
Inj.PHENARGAN 1CC IM/SOS
BP MONITORING 4TH HOURLY
Under observation for any episodes of dystonia
