A 70 yr old female with involuntary movements in upper and lower limb

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CHIEF COMPLAINT

Altered sensorium since 12:00 am midnight, involuntary movement in upper and lower limb since 12:00 am, loss of speech after 12:00 am

HISTORY OF PRESENTING ILLNESS

Pt was apparently asymptomatic 2days ago then she developed b/l involuntary movements in upper and lower limb,  loss of speech and recognition of people. Associated with drooling of frothy saliva from mouth,up rolling of eyes, biting of tongue.  No h/o fever,nausea, vomiting, headache, blurring of vision, diarrhoea, constipation. No postictal confusion

PAST HISTORY

K/c/o DM since 2 yrs and on medication

Not a k/c/o epilepsy, asthma, HTN, tuberculosis

No H/o previous surgeries

PERSONAL HISTORY

Diet: mixed

appetite: normal.

sleep: adequate, 

b&b movt: regular

addiction: tobacco  chewing 

FAMILY HISTORY  no significant family hisory

General examination

Pt is drowsy  E4VIM4

No pallor, icterus, cyanosis, clubbing generalized lymphadenopathy and oedema

Vitals

Bp 150/100 mmhg

Pulse 97 bpm

RR 20 cpm

Temperature 98.6

Spo2 94

Grbs 135 mg/dl (when measured in causality) ( ambulance driver gave history  of grbs 12 mg/dl at her home,started 25% dextrose)

SYSTEMIC EXAMINATION 

CNS 

                         Upper limb                               lower limb

                       Rt                    left               Rt            left

Tone     normal       normal      increased increased

Power           3/5                   3/5             3/5              3/5

Reflexes         right                left

Biceps              ++                   ++

Triceps            ++                   ++

Supinator       ++                   ++

Knee                ++                   ++

Ankle   

Plantar         flexon        extension 

https://youtube.com/shorts/-7N-84kWxAI?feature=share

Neck stiffness +

Kerning sign -

Brudzinski sign -

CVS S1,S2 +,no added murmurs

R/S NVBS heard

P/A  soft and non tender

Provisional diagnosis

?hypoglycemia 

? Viral encephalitis 

? Meningism

INVESTIGATIONS

DIAGNOSES 

Altered sensorium 2° to recurrent hypoglycemia with known diabetic

TREATMENT 

20/9/22

Inj levipil 1g  i.v stat

Inj levipil 500mg in 100 ml NS iv bd

Ivf 25% dextrose @20ml/hr iv infusion

Tab ecosporin-AV

INJ optineuron 1amp in 100ml NS iv over 30 min

Inj PAN 40mg iv od

Inj dextramethasone 4mg iv bd

Vitals monitoring 4th hrly

Grbs,spO2 monitoring hrly

Inj Monocef 2g iv tid

21/9/22

Altered sensorium 2° to recurrent hypoglycemia with known diabetic

With AKI

with episode of ?GTCS

? MENINGO ENCEPHALITIS 

? 2° TO VIRAL

?TB

Inf 25% dextrose stopped night 1am

On examination 

Pt is drowsy 

Gcs E4V4M6

Bp 140/70 mmhg

PR 80 bpm

SpO2 94%

Grbs 220 at 8 am

CVS s1 s2 +

R/s BLAE +

P/A SOFR NON TENDER 

CNS 

                         Upper limb                               lower limb

                       Rt                    left               Rt            left

Tone     normal       normal      increased increased

Power           3/5                   3/5             3/5              3/5

Reflexes         right                left

Biceps              ++                   ++

Triceps            ++                   ++

Supinator       ++                   ++

Knee                +                     +

Ankle   

Plantar         flexon        extension 

Rx

Inj levipil 500mg in 100 ml NS iv bd

INJ optineuron 1amp in 100ml NS iv over 30 min

Inj PAN 40mg iv od

Inj dextramethasone 4mg iv bd

Vitals monitoring 4th hrly

Grbs,spO2 monitoring hrly

Inj Monocef 2g iv tid

Inj HAI acc to grbs

22/9/22

Altered sensorium 2° to recurrent hypoglycemia (RESOLVED)

VIRAL MENINGO ENCEPHALITIS (RESOLVED)

WITH KNOWN CASS OF DM2

WITH CHOLELITHEASIS

WITH LEFT RENAL CORTICAL CYST

?WITH AKI ON CKD

COMPLAINT  sensorium improved

On examination 

Bp 110/60 mmhg

PR 82 bpm

Grbs 220 at 8 am

CVS s1 s2 +

R/s BLAE +

P/A SOFR NON TENDER 

I/O=1500/1400

Rx

Inj levipil 500mg in 100 ml NS iv bd

INJ optineuron 1amp in 100ml NS iv over 30 min

Inj Monocef 1g iv bd

Inj HAI acc to grbs

Grbs monitoring 

Ivf NS , RL at 50ml/hr iv

Vital monitoring 

Advice mobilize pt and shift to AMC

23/9/22

Diagnosis Altered sensorium 2° to recurrent hypoglycemia  resolved

WITH KNOWN CASS OF DM2

WITH CHOLELITHEASIS

WITH LEFT RENAL CORTICAL CYST

?WITH AKI ON CKD

No fresh complaints

On examination   pt is conscious 

Bp 110/80

PR 82bpm

Temp 98.5°f

CVS s1 s2 +

R/s BLAE +

P/A SOFR NON TENDER

Rx

Oral fluids 3 to 4L/day

Tab GLIPIZIDE 5mg od

Vital monitoring 

Advice at discharge 

Tab GLIPIZIDE 5mg once daily at 2pm

Tab ZINCOVIT once daily at 2pm

Oral fluids 3to 4 lts/day

Review to opd after 10 days