A 34 years female with involuntary movements of head and neck

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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 and treatment plan


CASE:-

A 34 years female housewife came to opd with chief complaints of

Involuntary movements of right side of neck and mouth opening since 1 day


HOPI:

Patent was apparently asymptomatic one day ago then she developed involuntary movements of neck towards right side with involuntary mouth opening
Then she developed two more episodes of similar movements each lasting for 15 to 30 minutes which got subsided with medications
No complaints of unconsciousness, altered consciousness,  weakness of limbs, tonic clonic movements, eye deviation, tongue biting, loss of sensations, altered sensations


Past history:

Hysterectomy done on 1/7/2023 haloperidol? was given in post operative period

Hysterectomy was done for fibroids


N/k/c/o DM, HTN, CVD, COPD, TB, Asthama, epilepsy 


Personal history:

Mixed diet
Appetite adequate
Sleep normal
Normal bowel and bladder movements


Menstrual history:

Age of menarche : 13 years
Regular 30 days cycle with normal flow no clots


Obstetric history:

1st child in 2020

2nd child in 2022


General examination:

Patient is conscious, coherent, cooperative well oriented to time, place and person

Moderately built and nourished
Temperature: afebrile
Bp: 110/70 mm Hg
RR: 16 cpm
SpO2: 96%


Systemic examination:

CVS: S1 and S2 heard no murmurs
CNS: No focal neurological deficits
RS: BAE + normal vesicular breath sounds


Provisional diagnosis:

P2L2 with 2 pervious LSCS with  TAH with BSO under spinal anaesthesia with cervical dystonia?

Investigations:







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