76 Female with hemiballismus secondary to uncontrolled sugars
A 66 yr old female ,residence of nalgonda came to the old with c/o
Slurring of speech since 15days
Involuntary movements of right upper limb since 10days
And right lower limb since 5 days
She was apparently asymptomatic 15days ago then she developed swelling of tongue f/b slurring of speech , insidious in onset and gradually progressive,no aggravating and relieving factors
Not associated with deviation of mouth
C/o involuntary movements of right upper and lower limb,insidious in onset and gradually progressive , aggravating on increasing sugars and decreasing with decrease in grbs levels
She also c/o skin lesions over genital region since 15days
Past history:
K/c/o HTN since 2 years
K/c/o DM since one week
She has h/o joint pains( shoulder and elbow) since 2-3 months for which she went to a local hospital and the reports shower RA FACTOR+
and was advised tab . methotrexate (on regular medication)
Personal history:
Diet :mixed
Appetite:normal
Bowel and bladder:regular but c/o burning micturition since 1 month
Sleep: adequate
Family history:not significant
General examination:
She is conscious,coherent , cooperative
Well oriented to time ,place and person
Vitals:
Temp:98.6F
Bp:120/70mmofhg
PR:118bpm
RR:20cpm
Grbs:339mg/dl
No pallor ,icterus ,clubbing ,cyanosis ,lymphadenopathy and edema
CVS:s1s2+,no murmur
RS:BAE+,no added sounds
P/A:
Inspection;
Shape of abdomen; obese
Position of umbilicus: central and inverted
No scars and sinuses are present
All quadrants are moving equally with respiration
Palpation:
No tenderness
No organomegaly
Auscultation:
Bowel sounds heard
CNS:
Motor system : RIGHT LEFT
Tone :UL: N N
LL: N N
Power: UL: 4/5 4/5
LL: 3/5 4/5
Reflexes:
Biceps:
Triceps :
Supinator:
Knee:
Ankle:
Plantar : flexion
OBG REFERRAL taken I/v/o reddish skin lesions over vulva and inner groin region,white discharge since 15days.
Diagnosis: 66year old p5L5 post hysterectomised with DM 2 and HTN with genital lesions
Advised :
Tab metrogyl for 5 days
T bact and clotrimazole ointment l/a bd
Strict perineal hygiene
1.inj.ceftrioxone 1gm iv stat f/b Tab.erythromycin 500mg po/BD
2.T.pantop 40mg po/OD
3.T.metronidazole 400mg po/TID
4.Antibiotic dosage can be escalated or deescalated after swab c/s report
Dvl referral taken I/v/o genital ulcer :
Diagnosis:Genital ulcer for evaluation+vulvo vaginal candidiasis
Advised :
1.clotrimazole 1%cream L/A BD for 1 week
2.Tab.BACT ointment L/A BD for 1 week
Review referral:
Diagnosis:Genital ulcer for Evaluation
?Frictional ulcer
?herpes genitalis + vulvovaginal candidiasis
Advised:
1.1.clotrimazole 1%cream L/A BD for 1 week
2.Tab.BACT ointment L/A BD for 1 week
3.continue same treatment as advised by physician
Opthalmology referral taken I/v/o HTN and DM retinopathy changes :
Impression: no diabetic and HTN retinopathy changes noted in both eyes.
Neurology referral taken I/v/o involuntary movements of right upper and lower limb
Diagnosis: Hemiballismus secondary to ?DM ?basal ganglia lesion
Advised:
1.Tetrabenazine 25mg po/BD if symptoms does not resolve can go for TID
Provisional diagnosis:
Right Hemiballismus secondary to ?Type II DM ?Basalganglia lesion
Hypokalemia Secondary to
?GI Losses ?Nutritional
Genital ulcer for Evaluation
?Frictional ulcer
?herpes genitalis + vulvovaginal candidiasis
K/c/o HTN 2yrs
Denovo DM-II (one week)
Investigations:
ECG:
2decho:
Treatment:
IVF NS and RL @75ml/hr
Inj.optineuron 1amp in 100ml Ns /iv/OD
Tab .amlodipine 5mg po/OD
Tab.tetrabenzine 25mg/poBD
Tab.metrogyl 400mg/po/TID
Tab.pan 40Mg po/OD
Tab.sporolac-Ds po/TID
Inj.HAI sc/TID acc to grbs
Syp.potklor 10ml/po/BDwith glass of water
T.bact ointment for LA /BD
Clotrimazole 1%cream LA/BD
Capsule redotil 100mg po/BD
Advice at discharge:
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