60/F with Ballismus

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This is a case of a 60 year old female with Ballismus

Chief complaints:
The patient was brought by her attendings to casualty with history of involuntary movements of both upper and lower limbs and head since 4 days. 

History of presenting illness:
Patient was apparently asymptomatic 6 days back. Then she had severe dragging pain in both upper and lower limbs. She was taken to the local hospital and was found to have high blood sugars (600 mg/dl). She was admitted for 2 days and treated with insulin injections. 

The day after the discharge, she suddenly had involuntary movements of all four limbs and head. No aggravating and relieving factors
No h/o aura, post ictal confusion, amnesia, loss of bladder control, uprolling of eyes
No complaints of fever, cold, cough, vomiting, loose stools, SOB, chest pain, facial puffiness, decreased urine output, orthopnea, PND
No h/o trauma, fever, vomiting, diarrhea

Past history:
K/c/o type 2 DM since 10 days
Not a known case of HTN, TB, asthma, epilepsy, CAD, thyroid disorders. 

Treatment history:
Patient was on 
Tab. Glimiperide 2mg PO/OD
Tab. Metformin 500mg PO/OD
Since 10 days


Personal history:
Marital status: Married
Occupation: housewife
Diet: mixed
Appetite: lost
Bowel movements: irregular
Micturition: normal
Alcohol consumption: occasional
No known allergies

Family history:
Not significant

Menstrual history:
Post menopausal

General examination:
No visible signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

Temp: 98.6°
PR: 56 bpm
RR: 20 cpm
BP: 90/60 mm Hg
Spo2: 100% at RA
GRBS: 83 mg%
GCS: E3V3M6

Systemic examination:
CVS: S1 S2 heard, No thrills and murmurs
RS: NVBS+
P/A: soft, non tender, bowel sounds heard
CNS:
Patient is drowsy
No signs of meningeal irritation
Cranial nerves - normal
Motor system:
Tone - RT UL normal, RT LL normal 
Power - RT UL 5/5, RT LL 5/5
LT UL 5/5, LT LL 5/5
Reflexes- normal

Course in the hospital:
A 60 YEAR OLD, DENOVO DIABETIC, WITH C/O SUDDEN VIOLENT, INVOLUNTARY, FLINGING/BALLISTIC MOVEMENTS OF B/L UPPER LIMBS, LOWER LIMBS AND HEAD SINCE 4 DAYS. 

ON ADMISSION HER VITALS WERE 
PR: 56 BPM, 
RR: 20 CPM, 
BP: 90/60 MMHG, 
SPO2 : 100% @ RA, 
GRBS: 83 MG/DL. 

HER LOW GRBS READINGS?SECONDARY TO ORAL HYPOGLYCEMIC AGENTS WAS TREATED WITH INJ. 25% DEXTROSE 100ML IV STAT FOLLOWED BY INJ. 25% DEXTROSE @40ML/HR. IT WAS SLOWLY TAPERED DOWN WITHIN 6HRS AND HER HYPOGLYCEMIA WAS CORRECTED. 

INITIALLY INJ. SODIUM VALPROATE 1G IV STAT, INJ. LORAZEPAM 4MG IV STAT WERE GIVEN. TAB. TETRABENAZINE 12.5MG WAS STARTED INTITALLY TWICE A DAY, THEN GRADUALLY INCREASED TO THRICE A DAY.

THOROUGH CLINICAL EVALUATION WAS DONE AND NECESSARY INVESTIGATIONS WERE SENT.

RYLES FEEDS WERE GIVEN.

USG ABDOMEN DONE ON 16/05/24 WHICH SHOWED BILATERAL GRADE II RPD CHANGES, BILATERAL SIMPLE RENAL CORTICAL CYSTS, RIGHT RENAL CALCULI. 

ON ADMISSION SR.CREATININE WAS 1.8 WHICH GRADUALLY REDUCED 1.0 DURING HOSPITAL STAY(ACUTE KIDNEY INJURY RESOLVED) 

PATIENT IS DIAGNOSED AS BALLISMUS SECONDARY TO METABOLIC CAUSE

Investigations:
HBsAg - RAPID Negative

Anti HCV Antibodies - Non Reactive

RFT 15-05-2024

UREA 24 mg/dl

CREATININE 1.8 mg/dl

URIC ACID 4.7 mmol/L

CALCIUM 8.6 mg/dl

PHOSPHOROUS 3.0 mg/dl

SODIUM129 mmol/L

POTASSIUM3.9 mmol/L.

CHLORIDE 98 mmol/L

LIVER FUNCTION TEST (LFT) 15-05-2024 

Total Bilurubin 0.90 mg/dl

Direct Bilurubin 0.19 mg/dl

SGOT(AST) 129 IU/L

SGPT(ALT) 45 IU/L

ALKALINE PHOSPHATASE 143 IU/L

TOTAL PROTEINS 5.0 gm/dl

ALBUMIN 3.4 gm/dl

A/G RATIO 2.14

RBS - 97 MG/DL

HEMOGRAM 15/05/24

HB: 9.0

TLC: 9,700

NEUTROPHILS: 84

LYMPHOCYTES: 12

EOSINOPHILS: 02

PCV: 25.7

MCV: 94.8

MCH: 33.2

MCHC: 35.0

PLT COUNT: 1.7

SERUM ELECTROLYTES: 16/05/24

SODIUM: 131

POTASSIUM: 3.7

CHLORIDE: 98

CALCIUM IONISED: 1.02

FBS - 249

2D-ECHO DONE ON 16/05/24

EF - 66%

IAS - ANEURYSM

IVC - 1.25CM, COLLAPSING

NO RWMA, MODERATE TR+ WITH PAH GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION

HBA1C - 6.4

THYROID PROFILE DONE ON 17/05/24

T3 - 0.61

T4 - 8.18

TSH - 1.63

LIPID PROFILE

TOTAL CHOLESTEROL - 111

TRIGLYCERIDES - 121

HDL - 35

LDL - 78

VLDL - 24.2

HEMOGRAM:17/05/24

HB: 10.5

TLC: 8000

NEUTROPHILS: 77

LYMPHOCYTES: 15

EOSINOPHILS: 03

PCV: 32.1

MCV: 84.0

MCH: 27.6

MCHC: 32.8

PLT COUNT: 2.7

USG ABDOMEN DONE ON 16/05/24

BILATERAL GRADE II RPD CHANGES

BILATERAL SIMPLE RENAL CORTICAL CYSTS

RIGHT RENAL CALCULI

MRI BRAIN PLAIN: ON 17/05/24

NO ABNORMALITY DETECTED IN BRAIN

SERUM ELECTROLYTES: 18/05/24

SODIUM: 137

POTASSIUM: 3.75

CHLORIDE: 105

CALCIUM IONISED: 1.13

Treatment given:
On 15/5/24:
1. Inj. Avil 25mg IV stat
2. Inj. Hydrocort 100mg IV stat
3. Inj. Lorazepam 4mg IV stat
4. Inj. Sodium Valproate 1g IV stat
5. Tab. Tetrabenazine 12.5mg PO stat

On 16/5/24:
1. Tab. Tetrabenazine 12.5mg PO OD
2. Tab. Nodosis 500mg PO BD
3. Tab. Shelcal CT PO OD
4. Ryles feeds added 
5. IV fluids given

On 17/5/24:
1. Ryles feeds
2. IV fluids
3. Tab. Tetrabenazine 12.5mg PO BD
4. Tab. Nodosis 500mg PO BD
5. Tab. Shelcal CT PO OD
6. Tab. Pregaba - NT 75mg PO HS
7. ORS

On 18/5/24:
1. Ryles feeds
2. IV fluids
3. Tab. Tetrabenazine 12.5mg PO BD
4. Tab. Nodosis 500mg PO BD
5. Tab. Shelcal CT PO OD
6. Tab. Pregaba - NT 75mg PO HS
7. ORS

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