60/F with Ballismus
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
