26 year old female with spasm of both hands

SUDHAMSHI REDDY M

This is online E log book to discuss our patient’s de-identified health data shared after taking   his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

 

I’ve 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  

26 year old female who is an employee in a private sector came to the casuality with complaints of 

-spasm of  both hands , since morning along with flushing of face since today morning . 

HOPI:

Patient was apparently asymptomatic ,one and half month back, then she suddenly developed tingling sensation of left lower limb which was gradually progressed to Right lower limb and bilateral upper limbs, followed by pain in  B/L lower limbs and B/L upper limbs

Spasms in B/L upper limbs and lower limbs, gradually progressive.

 Shortness of breath (grade 3-4) during the episode which subsides on taking medication.

Each episode lasts for 30min.

Flushing of face since childhood during any stress and anger episodes lasting for hours 

No chest pain, no sweating, no palpitations, no fever, no giddiness.

PAST HISTORY:

H/0 similar episodes in the past one to one and half month Not a K/C/O HTN, TB, DM, EPILEPSY, BRONCHIAL ASTHMA.

PERSONAL HISTORY:

Appetite normal

Diet mixed

Sleep normal

Regular Bowel and bladder habits

No allergies, addictions.

FAMILY HISTORY:

Mother is diabetic and hypertensive

GENERAL EXAMINATION:

O/E 

Patient is conscious, coherent, cooperative

Afebrile on touch

PR : 92bpm

RR : 16cpm

BP : 100/80 mm of hg

Grbs : 94mg/dl

SYSTEMIC EXAMINATION:

RS: BAE ,NVBS, no added sounds

CVS : S1 ,S2 heard no murmurs

P/A : soft , non tender

CNS:

HIGHER MENTAL FUNCTIONS- INTACT

MEMORY- able to recognise her family members and recall recent events

SPEECH: normal

CRANIAL NERVE EXAMINATION- normal

REFLEXES-

                      RIGHT          LEFT

BICEPS            3+                 3+

TRICEPS          2+                 2+

SUPINATOR     1+                1+ 

KNEE                2+                2+

ANKLE.            2+                 2+

SUPERFICIAL AND DEEP REFLEXES ARE PRESENT AND NORMAL

MUSCLE POWER- 

                                    RIGHT           LEFT 

UPPER LIMB  

ELBOW                         5/5                  5/5 

WRIST                           5/5                  5/5 

HAND GRIP                  5/5                  5/5

LOWER LIMB 

HIP                                   5/5                 5/5 

KNEE.                              5/5                 5/5 

ANKLE                            5/5                 5/5

TONE- NORMAL IN UPPER AND LOWER LIMBS

NO INVOLUNTARY MOVEMENTS

SENSORY SYSTEM- ALL SENSATIONS ARE NORMAL

INVESTIGATIONS:

Hb- 12.3gm/dl

TLC-11,600cells/cu.mm

PLT- 4.61lakhs/cu.mm

PT-16sec

INR- 1.11

BGT- B positive

BT- 2min0sec

CT-4min30sec

APTT- 31st c

RBS-102mg/dl

Blood urea-23mg/dl

Serum creatinine- 1mg/dl

Calcium- 10mg/dl

Na-137

K-4.1

Cl- 101

LFT

Tb- 0.68

Db- 0.23

AST-22

ALT- 17

ALP- 164

TP- 7.4

Alb- 4.37

A/G ratio- 1.44

Serum magnesium- 2.0mg/dl

USG ABDOMEN-

Impression:

Internal echoes noted in urinary bladder ? Cystitis

Right renal cortical cyst.

CHEST X RAY:

PROVISIONAL DIAGNOSIS:

HYPERVENTILATION SYNDROME

? CARCINOID SYNDROME

TREATMENT:

1.Tab PCM 650mg PO SOS

2.Tab MVT PO OD