A 33 year old female with c/c deviation and involuntary opening of moth
N.lavanya
Roll 93
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A 33 year old female resident of choutuppal house wife by occupation came to the general medicine opd on 3/7/23 night
Chief complaints
Paroxysmal involuntary opening of mouth with deviation to left and involuntary deviation of head and neck to both sides for about 10 min and on and off since 2 days
History of presenting illness
Patient was apparently asymptomatic one week ago
And 2 days ago Suddenly she developed paroxysmal
involuntary opening of mouth and involuntary deviation
of head and neck to both sides on and off
Had one episode on 2/7/23 and 2 episodes on 3/7/23
significantly after intake of food
Involuntary mouth opening was associated with mouth
deviation to left
Also there is an episode of seizure on 3/7/23 ago which
lasted for about 5 min
No H/o weakness of limbs
No H/o fever
No H/o loose stools
Patient underwent TAH ( total abdominal hysterectomy)
+ BSO. ( Bilateral Salpingo Oophorectomy )
3days back (1/07/2023)
(indication-anterior submural fibroid
Past History :
No previous similar complaints
Not 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 ( consumes non veg 3 times a week )
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 - No addictions
MENSTRUAL HISTORY
Age of menarche-13 yr
Regular cycle for 30 days cycle regular no visible clots
OBSTETRIC HISTORY
She got married at the age of 28 yr in 2019 non consanguinpus
Accidentally during the first pregnancy an anterior submural fibroid Was detected on one side
1st child ( girl ) in 2020 LSCS birth weight 3.5 kgs no
abnormalities and gave breast feeding for 6 months
Indication for Surgery is absent labour pains
2nd child in 2022 LSCS ( boy)
Indication same
Birth weight 3 kgs breast feeding for 2 yrs
Clinical images
EXAMINATION
temp-98.2f
Pulse rate -126 bpm
RR-16 cpm
BP-110/70mm of Hg
Spo2-96
GRBS-155
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 SENSATION 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 for 1 hr and then 1 cup of tea at 4:00 pm
Dinner at 7:30 ,and then she goes to bed by 8.30
PROVISIONAL DIAGNOSIS
P2L2 WITH 2 PREVIOUS LSCS WITH TAH WITH BSO UNDER SPINAL ANASTHESIA PID -3 WITH CEVICAL DYSTONIA?DRUG INDUCED ( mostly haloperidol suspected )
INVESTIGATIONS
Hemogram
Sr creatinine
Serum calcium
Serum electrolytes
On 4/07/2023
CUE
ABG
Chest x-ray
TREATMENT
Inj DIPHENHYDRAMINE 25 mg iv Stat SOS
Ophthalmology referral
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 at 12.00 pm and 7.30 pm
ON EXAMINATION
Patient is conscious coherent well oriented to place and time
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.
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