Case 41 - ALTERED SENSORIUM SECONDARY TO RECURRENT HYPOGLYCEMIA (RESOLVED) WITH VIRAL MENINGO ENCEPHALITIS (RESOLVED) WITH K/C/O DM-2 WITH CHOLILITHIASIS WITH LEFT CORTICAL CYST

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

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CHIEF COMPLAINT

Patient came to casualtiy with altered sensorium with involuntary movement in Right upper limb since 12:00 am, c/o loss of speech and no  movement  in left upper limb and lower limb after 12:00 am pt had h/o 3 episodes of involuntary micturition since  5 days , c/o one episode of fever  2 days back which was relieved on medication . On the way to the hospital PT grbs was found to be 15 mg/dl and a 25 d was connected after which the grbs was 131 mg /dl 

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 

PAST HISTORY

K/c/o DM since 2 yrs and on medication metformin 500 mg and pt medication was changed by local practioner to glimi m 1 8 days back from the presentation to the casualtiy.

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 

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

Vitals

Bp 150/100 mmhg

Pulse 97 bpm

RR 20 cpm

Temperature 98.6

Spo2 97

Grbs 81 mg/dl

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       mild extension 

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

CVS S1,S2 +,no added murmurs

R/S NVBS heard

P/A soft and non tender

Provisional diagnosis:

ALTERED SENSORIUM SECONDARY TO RECURRENT HYPOGLYCEMIA (RESOLVED) WITH VIRAL MENINGO ENCEPHALITIS (RESOLVED) WITH K/C/O DM-2 WITH CHOLILITHIASIS WITH LEFT  CORTICAL CYST

TREATMENT 

1) LEVIPIL 500 MG IN 100 ML NS/IV BD

  1------X--------1

8AM.            8PM

2) INJ. OPTINEURON.1AMP IN 100ML/NS/IV/OD OVER 30 MINTS

----------1--------------

3) INJ.HAI S/C ,ACC to GRBS 

4) GRBS MONITORING 70 PROFILE