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A 23 year old female patient,who is doing her Mba,presented to the opd with the chief complaints of involuntary movements of both upper limbs and lower limbs since when she was 5 years old.
History of present illness:
Patient was apparently asymptomatic 18 years back from then she developed involuntary movements of upper limbs and lower limbs.
5 years back on severity she was taken to hospital.There they prescribed some medicines.
2 years back she took ayurvedic medication for 6 months,by which her severity was less.
Now again since one month she developed increased involuntary movements of whole body.
Her involuntary movements are present mostly during night times during sleep & lasts for 2-5 mins.
She also developed painful skin lesions on her buttocks & lower limbs,caused by her involuntary movements.
Past History:
The patient was not a known case of hypertension,diabetes mellitus,bronchial asthma,epilepsy & tuberculosis.No history of any surgeries.
Personal history:
Occupation - student
Vegetarian diet
Bowel & bladder - Normal
Sleep inadequate
No addictions
Appetite -normal
Family history:
Her paternal grandfather had such involuntary movements in his childhood.
General Examination:
The patient is conscious,coherent and cooperative.She is well oriented to time,place and person.
Pallor
No Icterus
No Cyanosis
No Lymphadenopathy
No pedal edema
No clubbing
No koilonychia
Vitals
Temperature-Afebrile
Pulse rate-84 beats/min
Respiratory Rate- 14cpm
Blood pressure- 120/70 mmHg
SpO2 - 99% at room temperature
Systemic examination:
CVS :
S1 S2 + no murmurs
RS- BAE + , NVBS heard
per abdomen- Soft,non tender,BS +ve
CNS- Conscious,Speech normal.
Provisional diagnosis - ?Benign hereditary chorea,
?Acute pharyngitis, ?Eczema , ?Adjustment issues due to physical illness
Day 1
P- To start on tab tetrabenazine 12.5 mg po bd
Tab Augmentin 625mg po bd
Tab Sodium valproate 300mg
Tab levocitrezine 10mg po od
Salt water gargles
Momate f cream for local application bd
Mupirocin gel for local application bd
Day 2
Tab tetrabenazine 12.5mg
Tab Sodium valproate 300mg
Tab Augmentin 625mg po bd
Tab levocitrezine 10mg po od
Tab pantop 10mg
Tab Orofer xt
Salt water gargles
Momate f cream for local application bd
Mupirocin gel for local application bd
Day 3
Tab Tetrabenazine 25mg
Tab pan 40mg
Tab Orofer xt
Tab Augmentin 625mg po bd
Tab levocitrezine 10mg po od
Salt water gargles
Momate f cream for local application bd
Mupirocin gel for local application bd
Day 4
Tab Tetrabenzaine 25mg
Tab Pan 40mg
Tab Orofer xt
Tab Augmentin 625mg po bd
Tab levocitrezine 10mg po od
Salt water gargles
Momate f cream for local application bd
Mupirocin gel for local application bd
Day 5
Tab Amoxiclav 625mg
Tab levocitrezine 10mg po od
Salt water gargles
Momate f cream for local application bd
Mupirocin gel for local application bd
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