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A 23 year old female came to the OPD on 13/12/21 with the Cheif complaints of :-
-Chronic involuntary movements of hands and legs during sleep and on long standing and sitting position.
Sequence of events that might have led to the presentation of the patient:-
=>Patient was born in 1998
First born
NVD
Non Consanguinous
Appropriate to gestational age
Cried immediately after birth
No Antenatal and Natal Complications
H/o Secretions from mouth 3hrs after Birth.
=>At the age of 1 Year (1999)
-Abnormal movements of both UL and LL
(Rapid, Jerky and lasting for a Minute)
(No History of Loss of Consciousness, Vomiting)
-History of Fever, Throat Pain, Cough and Cold+.
-H/o Delayed Milestones
-H/o Behavioral issues- anger/anxiety with frequent spells
-H/o Abnormal movements (Chorieform) after getting up from bed during morning and at night.
=> At 3 years of age (2001)
- Started on Valproate
(Regular follow up) (Monthly)
-in the Month of April
C/o Inability to walk since 15 to 20 days
Associated with Fever
ON EXAMINATION:
Deep Tendon Reflexes- Absent
Plantar_ B/L Flexors??
Rx- Syp. Potklor
-in the Month of May
CT - Normal
EEG - Abnormal Stage II sleep recorded and Interictal discharges bihemispherically.
=> At the age of 7 years
Stopped AED??
Patient continued to have these episodes during sleep, more during early mornings, preceeded by brief arousal from sleep.
H/o Episodes + while getting up from sleep, standing after prolonged sitting, stress, during erection
(Few times during cycling)
- Patient aware of this episodes, followed by her leg pains used to stop activity before it starts.
=> At 13 years of age (2011)
EEG- Normal
Rx-
TAB. Tetrabenazine 25mg 1/2 Tab at Night.
TAB. Valproate 300mg BD
TAB. Clonazepam 0.5mg OD
=> At 16 years of age (2014)
Vitamin D- 4.21 (< 10 deficient)
Started on Vit. D capsule
( 1 TAB a week for 6 months)
- MRI (normal)
Patient continued to have similar episodes
H/o injuries to both limbs due to hitting the surroundings during the episodes
=> At 19 years of age (2017)
- Started Ayurveda medicines along with Tetrabenazine and clonazepam for 5-6 months.
=> At 20 years of age (2019)
- Started on Oxcarbazepine
(150- x -300mg)
- Video EEG done- Episodes in Favour of Paroxysomal Hypnogogic Choreoathetosis
=> Stopped medication for 2 years.
=> At 23 years of age (2021)
- Since past 2 months patient is having increased frequency of these episodes, more during the night, even on slight movement during sleep(3-4 hrs), lasting less than a minute along with pain in lower limb joints.
-H/o anger bursts at family members, decreased activity, depressed mood since 2 months.
Some more details about the patient's complaints:-
- skin lesions over buttocks and both limbs since 2 months
- patient has Throat Pain since 2 months
- difficulty in swallowing
-
History of past illness:-
- Not a k/c/o DM, HTN, epilepsy, asthma.
- patient has H/o heat and Cold intolerance
- patient has H/o recurrent oral ulcers
Personal history:-
- Appetite normal
- Mixed diet
- Sleep normal
- Bowel and bladder normal
- Addictions- none
General Examination:-
The patient was examined in well lit room after taking his consent.
- The patient was conscious, coherent and co operative. He was well Oriented to time, place and person
- No pallor, interus, cyanosis, clubbing, lymphadenopathy and oedema.
Vitals:-
- Temperature: afebrile
- Blood Pressure: 120/80
- Pulse Rate: 106 bpm
- SpO2: 98% at RA
- P/A- Soft
Systemic Examination:-
- CVS- S1, S2+
- RS- BAE+, NVBS
- P/A- Soft and Tender
- GIT- Bowel sounds+
- CNS-
Investigations:-
Update on patient:-
Date:- 14/12/2021
In the evening - patient had one episode of mild fever which subsided on taking medication.
Temp:- 100.9
PR- 86/ min ,regular
BP- 110/70 mmhg
RR- 20 / min
Spo2- 98%
RS- BAE present
CvS- S1,S2 heard
P/A- Soft
Patient was advised to take these medications:-
TAB Tetrabenazine 25mg TID
TAB Sodium Valproate 300mg BD
TAB Augmentin mg BD
TAB Levocet 10 mg BD
TAB Becosules OD
TAB Teczine 10 mg OD
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