70 year old female with involuntary movements of bilateral upper limbs and lower limbs

 This is an 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 patient's 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 the comment box.

CASE PRESENTATION:

This is a case of 70 year old female with chief complaints of involuntary movements of Bilateral upper limbs and lower limbs since 2 days.

History of presenting illness:

Patient was apparently asymptomatic 5 days ago 

* then she developed fever which is high grade , intermittent type , associated with chills  

*vomitings for 2 days which is no blood stained , non projectile , relief after Emesis 

*diagnosed with dengue and was given 2 bottles of saline in local  hospital , but the fever did not subside 

*then she got admitted in city hospital. They ordered tests which shows 37K platelet count 

* Platelet count  was 30K - 37K - 40K

*patient also had involuntary movements of bilateral upper limbs and lower limbs.

Patient is agitated and decreased talking since morning 

No h/o uprolling of eye balls

No h/o involuntary micturition 

No h/o tongue bite 

No h/o trauma , shortness of breath , head injury

No h/o tremors 

Past history :

Not a known case of diabetes Miletus , hypertension , asthma , epilepsy , tuberculosis , seizures 

No similar complaints in past 

Cataract surgery 1 year back 

Family history :

No significant family history 

Personal history :

 Diet - mixed 

Bowel and bladder movements - regular 

Sleep - adequate 

Addictions - chutta stopped 1 year back 

Occasionally todddy drinker and stopped 20 years back 

Examination :

General examination :

Patient was coherent ,cooperative and not oriented to time but oriented to place , person 

 No pallor , icterus , cyanosis , clubbing , cyanosis , lymphadenopathy 

Vitals:

Afebrile 

Pulse rate : 64 bpm

Bp : 110. / 80 

Rr : 17 cpm 

Systemic examination: 

CVS - s1, s2 are heard ; no murmurs heard 

Reparatory : no abnormal breath sounds 

Head to toe examination : 

Hair - normal 

Eyes , ear , nails - normal 

Nose - no deformity 

Chest , abdomen , spine - normal 

Cns examination : 

She is in altered sensorium with her gcs being 

E3V1M5(eye opening on calling,inappropriate sounds,localising pain)

Agitated 

Grasping very lately 

Neck stiffness was Present

brudzinski sign was positive

Cranial nerve examination : 

1 - normal

2 - visual acuity : counting fingers 

3 , 4 ,6 - she is moving eyes in all directions 

5 - facial sensation is seen , chewing movements are normal 

8 - hearing is normal 

No tongue deviation 

11 - shoulder shrug is seen 

Motor examination : 

Muscle tone 

U/L.      Increased   Increased 

L/L.      Increased    Increased 

Tremors +

Involuntary movements +

 

Muscle power : couldn’t Be elicited 

Moving all four limbs 

Sensory examination 

Fine touch - present 

Pain- responding 

Temperature - afebrile 

Vibration - felt 

Meningeal signs : 

Neck stiffness - seen 

Brudknzki sign - positive 

Kernings sign - positive 

     

Investigations : 

                                  02/11/22

                              Blood urea : 79

Rbs - 115 mg/Dl 

03/12/22

 

04/12/22

Provisional diagnosis : 

Altered sensorium secondary Hyponatraemia ? Meningoemceohalitis(viral dengue positive)

Metabolic alkalosis secondary to GI losses/hypokalemia

Treatment : 

On 4/12/22

1. 02 supplementation to maintain sat> 92%

2. Ryles feed-  milk with protein powder(100 ml 4th hrly)

- water 100 ml 2nd hrly

3.INJ.DEXA 8 MG/IV/TID(D2)

4.INJ.MONOCEF 2G/IV/BD(D2)

5.IVF NS@ 50 ML/HR IV CONTINUOUS INFUSION 

6.INJ.OPTINEURON 1AMP +  100 ML NS

7.VITALS ,GRBS MONITORING 4TH HRLY

DISCUSSION -