70 year old female with involuntary movements of bilateral upper and lower limbs
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CASE PRESENTATION
70 year old female resident of miryalguda came with chief complaints of
• history of fever since 4 days
•involuntary movements since 2days
HISTORY OF PRESENTING ILLNESS
patient was apparently asymptomatic 4days back and then she developed fever which was insidious in onset, intermittent,high grade associated with chills and rigors.
Associated with two episodes of vomiting which is non projectile, non blood stained,contents with undigested food and abdominal pain which relieved after emesies.
She was taken to the local hospital and diagnosed to have dengue and treated for the same.
Then patient developed involuntary movements of both upper and lower limbs which was sudden in onset and associated with altered mental status
No h/o tongue bite,uprolling of eyes
No h/o involuntary micturation, bowel movements
No h/o head injury,head ache,blurring of vision
PAST HISTORY
No similar complaints in the past
No h/o hypertension, diabetes, tuberculosis, seizures, coronary vascular diseases.
PATIENTS DAILY ROUTINE
Patient would wake up everyday at 7AM and do her everyday rituals,then she would have her breakfast which is mostly dal and rice
She used to work in the farm fields 10 years back and stopped working now because of her age.
She now passes her time by watching television. She takes her lunch at 2pm followed by short nap in the afternoon,dinner at 8pm and goes to sleep by 9pm.
MARTIAL HISTORY
Married at the age of 20.
1st,2nd,3rd child at 25,28,30 years respectively through normal delivery
SURGICAL HISTORY
She underwent tubectomy at the age of 34.
Cataract surgery-1year ago
FAMILY HISTORY
No significant family history
PERSONAL HISTORY
Diet- mixed,consumes rice on daily basis, non vegetarian foods occasionally
Appetite-normal
Sleep-adequate
Bowel and bladder- regular
addictions - smoker (chutta) since 30 years stopped 1year ago
Toddy consumption stopped 20 years ago
GENERAL EXAMINATION
Patient is conscious, coherent, cooperative well orientated to time, place and person moderately built and nourished.
No signs of pallor, icterus, cyanosis, clubbing,lymphadenopathy .
VITALS
temperature 37.7°C
BP 110/80 mm hg
Pulse rate 70bpm
Respiratory rate 18cpm
Saturation 96% on room air
GCS Scoring
E4 - spontaneous eye opening
V5-fully oriented
M6-obeys commands
Total score-15
HEAD TO TOE EXAMINATION
Hair :normal
eyes :normal
ears :normal
no deviation of the mouth
Nails:no discoloration
Skin: pigmentation of upper limbs
chest: normal , no scars
Abdomen:normal
spine: no deformity
SYSTEMIC EXAMINATION
Higher mental functions
Speech comprehensive
Consciousness -lethargy
Behavior - cooperative
Spine - no deformity
Cranial nerve examination
1st nerve: olfactory normal
2nd optic nerve
Visual acuity: counting fingers
3rd 4th 6th nerve: oculomotor ,trochlear,abducens
Primary gaze present
EOM RT LT
SR n normal
IR normal
SO normal
IO normal
Ptosis absent
Pupils reactive to light
5th nerve RT LT
Corneal reflex + +
Jaw jerk + +
Sensation over the face-present
7th nerve;
Frowning absent
Orbicularis oculi
Nasolabial fold present
8th nerve
Vestibular cochlear
Rt left
Rinnies + +
Webbers + +
9th nerve
Uvula central
10th nerve
Gag reflex present
11th nerve
Symmetrical
Motor system
Muscle bulk normal
Muscle tone normal
Power:
Grade 3 against gravity
Coordination movements normal
Reflexes: Rt left
Corneal + +
Abdominal + +
Plantar + +
Deep Reflexes
Jaw jerk + +
Biceps jerk + ++
Supinator jerk ++
Triceps jerk + +
Knee jerk + +
Ankle jerk+ +
SENSORY SYSTEM
fine touch present
pain responding
Temperature felt
Vibration felt
MENINGEAL SIGNS
Brudzinikies sign positive
Neck stiffness positive
Kerning sign negative
Apex beat was felt in the 5 th inter coastal space medial to the mid clavicular line
Jvp was normal
No precordial bulge
No parasternal heave
-S1,S2 heard no murmurs
RS-
On inspection
Chest is b/l symmetrical
Expansion of chest equal on both sides
Position of trachea -central
No visible scars sinuses
On palpation
Expansion of chest was equal on both sides
Position of trachea -central
Tactile vocal fremitus -was felt
On percussion
all lung areas resonant
On auscultation
BAE + ,wheeze present
Vocal resonance - all areas resonant
PER ABDOMEN -soft ,tender on palpation and no organomegaly
Umbilicus -Inverted
bowel sounds - heard
INVESTIGATIONS
on 4-12-2022
CSF EXAMINATION
GLUCOSE- 57mg/dl
PROTEIN-15mg/do
Chloride-109
FINAL DIAGNOSIS
VIRAL MENINGO ENCEPHALITIS with hyponatremia
TREATMENT
1. 02 supplementation to maintain sat> 92%
2. Ryles feed- milk with protein powder(100 ml 4th hrly)
- water 100 ml 2nd hrly
3.INJ.DEXA 8 MG/IV/TID(D2)
4.INJ.MONOCEF 2G/IV/BD(D2)
5.IVF NS@ 50 ML/HR IV CONTINUOUS INFUSION
6.INJ.OPTINEURON 1AMP + 100 ML NS
7.VITALS ,GRBS MONITORING 4TH HRLY
DISSCUSSION
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