A lady who was married at the age of 15 years and who conceived 5 children 4 boys and 1 girl, had lost her first 2 children both boys at the age of 6 months to 1 year. Later she lost her husband at the age of 41 years. She was told that her husband had died because of Kidney failure. At the age of 45 she lost her eldest son. She was quiet disturbed with the loss of her husband and eldest son.
                                         She had complaints of dizziness on and off since 4 years, she was diagnosed to be having low Blood pressure and was given salt. 3 years back she had developed a wound on the hand which got infected and then she was diagnosed to be having diabetes mellitus and was started on Glycomet M1. She also had complains of generalised weakness and paraesthesia of all the limbs since 1 year. She had complains of generalised weakness , giddiness , parenthesias on and off. She had a hypoglycaemic episode 6 months back for which her oral hypoglycaemic dose had been changed.
                                         Since the past one week she had fever which was high grade associated with chills. The family took her to a local hospital where she was treated and her fever subsided. Later after 2 days she developed loose stools and  Vomitings. The stools were watery in consistency, non foul smelling, no h/o any mucous discharge or blood in the stools. She had almost 10-15 episodes per day for 2days.  Vomitings were 5-6 episodes content being food.  She was taken to the local hospital where she was put and given iv fluids for 2 days. The son says that she had been on iv fluids for 2 days about 10-15 units of fluids were given per day. 
                          

 Daughters version

 At around midnight the patient had gone for washroom after which there was a swaying the gait so much that she had to take support of the wall and a bottle which had been put near the foot end of the bed had fell down because of her swaying. She spoke to the attender then she slept. Early in the morning when the patient did not wake up the attenders tried waking her up but she did not get up. She just opened and closed her her eyes intermittently. 

Son’s version

At around midnight the lady had a fall from the bed which she attributed to having a bad dream. The son took her up and then asked whether she hurt herself for which she replied after few minutes. After replying and telling him about the dream she slept. Early in the morning when the patient did not wake up the attenders tried waking her up but she did not get up. She just opened and closed her her eyes intermittently. 

GENERAL EXAMINATION
A old lady of 55 years of age who is moderately built and nourished is responding to painful stimuli by just moving her limbs ( a flicker of movement in the fingers).
Her GCS 6/15
No evidence of pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy 
Pedal edema 




CENTRAL NERVOUS SYSTEM EXAMINATION

Responding  to painful stimuli by just moving her limbs ( a flicker of movement in the fingers).
Dolls eye reflex could not be elicited
Pupils are bilaterally reacting to light equally.
Motor Response
Flaccid tone bilaterally in all the limbs
No resistance to any movement of the limb

REFLEXES
                       Right                      Left
Biceps.           1+                               1+
Triceps.         1+                              1+
Supinator      -                                  -
Knee.             1+.                              1+
Ankle.             -                                  -
 Plantars.         Bilaterally extensor





COMPLETE BLOOD PICTURE

HB- 10.7 gm%
TLC- 11000
Neutrophils- 82
Lymphocytes-13
Eosinophils-02
Monocytes-03
Platelets-3.10 lakh

RENAL FUNCTION TESTS
Urea- 15
Creatinine-0.8
Uric acid -6.2
Calcium-10.2
Phosphorus- 4.4
Sodium- 145 
Potassium- 3.0
Chloride-101

COMPLETE URINE EXAMINATION
Albumin 1+
Pus cells-4-5
Epithelial cells 2-3

GLYCOSALATED HEMOGLOBIN-7.4

Had planned for a Lumbar puncture because of the altered sensorium which she was in. Her CSF Analysis revealed:
A colourless clear fluid with 2 cells which are lymphocytes and 1-2 RBC cells were seen.
The gram stain of the CSF revealed no growth .

Her BLOOD and URINE culture revealed no growth.

We had started her on 
Ceftriaxone
Acyclovir and
Artesunate 

After 2 days of hospital stay she started moving her limbs and started staring staring people. She would not speak or stare for long. She would be awake with open eyes when we held her and made her to stand. She even took a few steps when made to stand.  After 6 days of hospital stay in the evening  she started shouting irrelevantly and stating that SHE IS FROM AMERICA. 

A psychiatry opinion was taken after which the psychiatrist advised to take the following medication.
Modafinil
Encorate
Arachdonic acid
Piracetam
Bupropion





Comments

  1. caregiver7careseeker6 March 2018 at 20:32

    Another resident's version

    A 55 y F field worker by occupation resident of kapuriyath suryapeth came with decreased consciousness to the casualty
    Hopi-patient was apparently alright 4 years back then she developed dizziness on and off multiple times a day without any fall when she was taken to a local hospital where her blood pressure was found to be low.
    She was advised to taken high salt diet.
    She also developed burning sensations of hands and feet since 4 years
    Her dizziness and burning sensation continued for another 2 years and had developed a wound on rt hand when she was taken to a local hospital and was diagnosed of DM type 2
    4 months back she had chest pain and pain in her left arm when she started taking ecosprin
    3 months back vogliboseM1 was changed to glycomet M1 od which was later changed to half od
    1 wk back she had fever with chills when she was taken to a local doctor where she was given dolo 650
    Fever subsided
    Then 2 days back she developed loose stools 10 episodes when she was admitted to local hospital and treated
    Loose stools subsided then
    She had dizziness in the night following which she went to sleep . In the morning she was in altered sensorium . Her grbs was checked and it was 35mg/dl.she was given 25%d and later GRBs was 400mg/dl.She was in altered sensorium when she was bought to our hospital

    ReplyDelete

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