65F with HHS ,HEMIBALLISM,CHOREA-ATHETOSIS ,LEFT SIDED UNILATERAL PULMONARY EDEMA , CHRONIC UTI ,HYPOTHYROIDISM , DIABETIC NEPHROPATHY with TYPE 2 DM AND HTN
DOA - 7/2/2023
DischargeDate
Date:17/2/2023
Ward: AMC
Unit:GM 2
Diagnosis
HHSWITHHEMIBALLISM,CHOREA-ATHETOSIS[MOVEMENTSRECOVEREDAFTER4DAYS] LEFT SIDED UNILATERAL PULMONARY EDEMA [SECONDARY TO ACUTE CORONARY SYNDROME][RECOVERED IN 4 DAYS]
ANEMIA[? NUTRITIONAL CAUSE ?ANEMIA ]
CHRONICUTI[MEROPENEMRESISTANTANDFOSFOMYCINSENSITIVEE.COLI] HYPOTHYROIDISM [15 YEARS,PRESENTLY ON TABLET THYRONORM 75MCG ] DIABETIC NEPHROPATHY[SERUM CREATININE-2.8 ON 10/2/2023]
K/C/OTYPE2DM[SINCE30YEARS]HBAIC-7%ON8/2/2023ANDK/C/OHTNSINCE[SINCE15 YEARS]
Case History and Clinical Findings
CHIEF COMPLAINTS-
GENERALISEDWEAKNESSSINCE1WEEK COUGH SINCE 4 DAYS
INVOLUNTARYMOVEMENTSOFLTUPPERLIMBSINCE1DAY
HOPI-
PTWASAPPARENTLYASYMPTOMATIC1WEEKAGOTHENSHEDEVELOPEDGENERALISED WEAKNESS
H/O COUGH SINCE 4 DAYS ,PRODUCTIVE, SCANTY SPUTUM -WHITE TO YELLOW IN COLOUR
,NON BLOOD STAINED ,NON FOUL SMELLING
H/OINVOLUNTARYMOVEMENTSOFLTUPPERLIMBSINCE1DAY[TOANDFRO MOVEMENTS]
H/OINADEQUATELYCONTROLLEDSUGARSFROM4MONTHS H/O FALL ONE WEEK AGO
NOH/OVOMITING,SOB,LOOSESTOOLS,PAINABDOMEN,BURNINGMICTURITION NO H/O FEVER,COLD,SORE THROAT
NO HISTORY OF SPEECH ABNORMALITIES
NOH/OWEAKNESSINTHEUPPERANDLOWERLIMB NO H/O LOSS OF CONSCIOUSNESS, MEMORY LOSS NO HISTORY OF ABNORMAL POSTURING
H/OFALLFROMBEDANDCOMPLAINTSOFPAININTHEHIPWHICHISGRADUALLY RESOLVING
K/C/OTYPE2DIABETESMELLITUSSINCE30YRS,ONINSULIN10YRS (INSULIN LISPRO 20 -X-20 )
K/C/OHTNSINCE20YRSONTPROMOLETXL50MGPO/ODAT10AMANDTATENOLOL25 MG PO/OD
K/C/O HYPOTHYROIDISM SINCE 15 YRS ON THYRONORM 75 MCG
K/C/ORECURRENTURINARYTRACTINFECTIONFORWHICHSHEHOSPITALISED1YRBACK NOT A KNOWN CASE OF TUBERCULOSIS,EPILEPSY ,ASTHMA ,CEREBRO VASCULAR ACCIDENT ,CORONARY ARTERY DISEASE .
PERSONAL HISTORY:
DIET- MIXED APPETITE-LOST
BLADDERMOVEMENTSWEREREGULAR NON ALCOHOLIC ,CHEWS TOBACCO
CHEWSBETELNUTANDBETELLEAFTWICEDAILY NO ALLERGIES
FAMILY HISTORY-
NO H/O SIMILAR COMPLAINTS IN FAMILY
O/E OF PATIENT ON ADMISSION-
PTISCONSCIOUS,COHERENT,NONCOOPERATIVE TEMP : 96.4 F
PR : 76 BPM
BP:110/70MMHG RR : 18/MIN
SPO298%ATROOMAIR GRBS : 315 MG /DL PALLOR PRESENT
NOICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY. BILATERAL PITTING TYPE EXTENDING UP TO KNEE
CVS : S1 S2 HEARD NO MURMURS
RS:BILATERALAIRENTRY+NORMALVESICULARBREATHSOUNDS+ P/A : SOFT ,NON TENDER
BOWELSOUNDSHEARD CNS-
MOTOR SYSTEM-
NORMALTONEINBOTHUPPERANDLOWERLIMBS POWER 5/5 IN ALL LIMBS
REFLEXES B / T / S / K / A / P
RT1+/1+/-/1+/-/F LT 1+ / 1 + / - / 1 + / - / F
SENSORYEXAMINATIONNORMAL NO CEREBELLAR SIGNS
NORMALGAITANDNOMENINGEALSIGNS GCS SCORE E4V5M6
O/E OF PATIENT ON DISCHARGE-
PT IS CONSIUOS ,COHERENT , COOPERATIVE
TEMP:97.4F PR : 76 BPM
BP:130/60MMHG RR : 18/MIN
SPO298%ATROOMAIR GRBS : 191 MG /DL
CVS : S1 S2 HEARD, NO MURMURS
RS:BILATERALAIRENTRY+,NORMALVESICULARBREATHSOUNDS+ P/A : SOFT ,NON TENDER,BOWEL SOUNDS HEARD
CNS-
MOTORSYSTEMNORMALTONEINBOTHUPPERANDLOWERLIMBS POWER 5/5 IN ALL LIMBS
REFLEXES B / T / S / K / A / P
RT1+/1+/-/1+/-/F LT 1+ / 1 + / - / 1 + / - / F
SENSORYEXAMINATIONNORMAL NO CEREBELLAR SIGNS
NORMALGAITANDNOMENINGEALSIGNS GCS SCORE- E4V5M6
COURSE IN HOSPITAL-
A65YROLDFEMALECAMETOTHETHECASUALTYWITHCOMPLAINTSOFGENERALISED WEAKNESSSINCE1WEEK,COUGHSINCE4DAYSANDINVOLUNTARYMOVEMENTSOFLT UPPER LIMB SINCE 1 DAY
H/O INADEQUATELY CONTROLLED SUGARS FROM 4 MONTHS
PT WAS EVALUATED WITH CLINICAL EXAMINATION AND AFTER NECESSARY INVESTIGATIONS, SHE WAS DIAGNOSED AS HYPERGLYCEMIA WITH CHOREA WITH DIABETICNEPHROPATHYWITHRECURRENTURINARYTRACTINFECTIONWITHIRON DEFICIENCY ANEMIA
ANDFOLLOWINGTREATMENTWASGIVEN- NBM TILL FURTHER ORDERS
INJHAI6U/IV/STATANDFOLLOWEDBYINSULININFUSION1ML/HR IVF NS @ 75 ML/HR
IVF 5D @ 50 ML/HR
GRBS AND VITALS MONITORING HOURLY
USGABDOMENANDPELVISSHOWEDBILATERALGRADE1-2RPDCHANGESWITHRAISED ECHOGENICITY
ECG SHOWED NORMAL SINUS RHYTHM
DAY 2
INVOLUNTARY MOVEMENTS OF LT UPPER LIMB NOT REDUCED
INSULININFUSIONCHANGEDTOSUBCUTANEOUSROUTE,HAIANDNPHGIVEN ACCORDING TO GRBS
TPROMOLETXL50MGPO/ODAT8AM,TTHYRONORM75MCGPO/ODAT7AM,T TETRABENAZINE 12.5 MG PO/OD AT 8 AM ADDED TO THE TREATMENT
T ATENOLOL WAS WITH HELD
OPHTHALMOLOGYOPINIONWASTAKENINVIEWOFANYDIABETICANDHYPERTENSIVE RETINOPATHY CHANGES
ONFUNDUSEXAMINATIONNOCHANGESWERENOTEDINRETINA. 2D ECHO WAS DONE SHOWED-
NORWMA,CONCENTRICLVH+ MILD MR+/AR+;TRIVIAL TR+ SCLEROTIC AV ,NOAS/MS
EF 58% ,RVSP=35 MMHGGOODLVSYSTOLICFUNCTION
DIASTOLICDYSFUNCTION+,NOPE IVC SIZE (1.O7CMS) COLLAPSING
DAY 3
INVOLUNTARYMOVEMENTSWEREREDUCEDCOMPAREDTOPREVIOUSDAY INJ NPH WAS WITH HELD
DERNATOLOGYOPINIONWASTAKENINVIEWOFDRY,BROWNSCALYLESIONSONBOTH BOTH LEGS EXTENDING TILL KNEES
AND WAS DIAGNOSED AS SNILE XEROSIS AND ADVICEDLIQUIDPARAFFINL/ABDFOR4WEEKS T TECZINE 5 MG SOS
BLOOD SENT FOR CULTURE SENSITIVITY SHOWED NO GROWTH NEUROLOGY OPINION WAS TAKEN AND ADVISED FOR MRI BRAIN
ANESTHESIOLOGIST OPINION WAS TAKEN FOR SEDATION FOR MRI
SOPACWASDONEI/V/OMRIUNDERSEDATION.PATIENTATTEDERSWEREEXPLAINED ABOUT THE PROCEDURE AND POSSIBLE RISKS ASSOCIATED WITH MRI SEDATION
BUT PATIENT ATTENDERS REFUSED TO GIVE CONSENT AND MRI BRAIN WAS NOT DONE
DAY 4
INVOLUNTARY MOVEMENTS WERE REDUCED COMPARED TO PREVIOUS DAY
CULTUREANDSENSITIVITYOFURINESAMPLESHOWSESCHERICHIACOLI>100000CFU/ML OF URINE ISOLATED AND 5-6 PUS CELLS SEEN /HPF .
SENSITIVITYSEENTOGENTAMICIN,FOSFOMYCIN,ANDAMIKACIN INTERMIDIATE SENSITIVITY SEEN TO NITROFURANTOIN RESISTANT TO
AMOXYCLAV,CEFUROXIME,NORFLOX,COTRIMOXAZOLE,OFLAXACIN,CEFTAZIDINE,CEFEPIM
E,PIPERACILLIN/TAZOBACTAM.
DAY 5
SLIGHTINVOLUNTARYMOVEMENTSWERENOTED INSULIN DOSE WAS FIXED ,HAI 8U----8U 8U
DAY 6
REDUCED INVOLUNTARY MOVEMENTS COMPARED TO PREVIOUS DAY
DAY 7
PATIENTISSHIFTEDTOICUAT12AMINVIEWOFFALLINGSATURATIONS60%ATROOM AIR AND FEVER 100.7F
COMPLAINTS OF SHORTNESS OF BREATH
SHE WAS PUT ON INJ AUGEMENTIN 1.2 G IV BD
NEBULIZATIONWITHBUDECORTANDMUCOMIST8THHOURLY INTERMITTENT CPAP
TAB NICARDIA 10MG PO/OD STAT GIVEN
PATIENT CONDITION HAS BEEN EXPLAINED TO THE ATTENDERS IN THEIR OWN UNDERSTANDABLELANGUAGEABOUTTHERISKASSOCIATEDWITHTHECONDITIONAND IN NEW FALLING SATURATION AND POSSIBLE NEED FOR EMERGENCY INTUBATION
CHESTXRAYWASDONEWHICHSHOWEDLEFTSIDEDOPACIFICATION[?CARDIOGENIC PULMONARY EDEMA ?PNEUMONIA]
DAY 8
INVOLUNTARYMOVEMENTSREDUCEDCOMPAREDTOTHEPREVIOUSDAY PATIENT COMPLAINS OF COUGH WITH EXPECTORATION
SPUTUM FOR AFB,GRAM STAIN AND ULTURE AND SENSITIVITY SEND
PULMOOPINIONWASTAKENI/V/OHOSPITALACQUIREDPNEUMONIAANDON EXAMINATION BILATERAL AIR ENTRY PRESENT
CREPSPRESENTATINFRASCAPULARREGIONLEFT.RIGHTANDINTERSCAPULARREGION AND LEFT IAA
THEYADVISEDCST,SYRUPASCORILLS2TSPPOTID,NEBULIZATIONWITHMUCOMIST BD,AND PLAN FOR BRONCHOSCOPY ONCE THE PATIENT IS STABLE
2D ECHO WAS DONE
RWMA PRESENT,LAD HYPOKINESIA,MILD LVH PRESENT [1.28CM]
MILDMRPRESENT,MODERATETOSEVERETRPRESENTWITHPAH,MODERATEAR PRESENT
SCLEROTIC AV NO AS/MS
EF52%FAIRTOMILDLVDYSFUNCTION DIASTOLIC DYSFUNCTION PRESENTNO PE
IVCSIZE[1.64CM]DILATEDCOLLAPSING MILD DILATED RA/LA
DAY 9
NOFEVERSPIKESSINCEPREVIOUSDAY INVOLUNTARY MOVEMENTS ABSENT TAB TETRABENAZINE STOPPED
COUGHWITHEXPECTORATIONREDUCEDCOMPAREDTOTHEPREVIOUSDAY INJ HAI S/C GIVEN TID 8 UNITS AT AM-1PM-8PM
SPUTUMFORCULTURESENSITIVITY-PSEUDOMONASSPECIESISISOLATED SENSITIVE TO
PIPERACILLIN,GENTAMICIN,CIPROFLOXACIN,CEFTAZIDIME,AMIKACIN,CEFEPIME,TAZOBACT
EM,MEROPENEM
DAY 10
NOFEVERSPIKESSINCEPREVIOUSDAY INVOLUNTARY MOVEMENTS ABSENT
COUGH WITH EXPECTORATION REDUCED COMPARED TO THE PREVIOUS DAY
DAY 11
NO COMPLAINTS AND PT WAS DISCHARGED IN HEMODYNAMICALLY STABLE STATE
Investigation
2D ECHO WAS DONE SHOWED NORWMA,CONCENTRICLVH+ MILD MR+/AR+;TRIVIAL TR+ SCLEROTIC AV ,NOAS/MS
EF 58% ,RVSP=35 MMHGGOODLVSYSTOLICFUNCTION
DIASTOLICDYSFUNCTION+,NOPE IVC SIZE (1.O7CMS) COLLAPSING
USG ABDOMEN WAS DONE SHOWED
BILATERAL GRADE 1 -2 RPD CHANGES WITH RAISED ECHOGENICITY
ECG SHOWS NORMAL SINUS RHYTHM
HBA1C 7%
HAEMOGRAM OF PT SHOWS HAEMOGRAMHB/TLC/RBC/PLT 7/2/23 7.9 / 13,100 / 4.34 / 2.50
8/2/23 8.4 / 11,000 / 4.55 / 2.99
11/2/23 8.0 / 13,700 / 4.31 / 2.74
SERUMOSMOLALITY 277.9
SPOT URINE PROTEIN 90.5
SPOT URINE CREAT 25.7SPOT URINE PROTEIN/CREATININE RATIO 3.52
CULTUREANDSENSITIVITYOFURINESAMPLESHOWSESCHERICHIACOLI>100000CFU/ML OF URINE ISOLATED
AND 5-6 PUS CELLS SEEN /HPF .
SENSITIVITYSEENTOGENTAMICIN,FOSFOMYCIN,ANDAMIKACIN INTERMIDIATE SENSITIVITY SEEN TO NITROFURANTOIN RESISTANT TO
AMOXYCLAV,CEFUROXIME,NORFLOX,COTRIMOXAZOLE,OFLAXACIN,CEFTAZIDINE,CEFEPIM
E,PIPERACILLIN/TAZOBACTAM.
URINE FOR KETONE BODIES WERE NEGATIVE
BLOOD SENT FOR CULTURE SENSITIVITY SHOWED NO GROWTH
SPUTUM FOR CULTURE SENSITIVITY -PSEUDOMONAS SPECIES IS ISOLATED
Treatment Given(Enter only Generic Name)
INJHAISUBCUTANEOUS8U---8U---8U[8AM--1PM--8PM] IVF NS @ 75 ML/HR
INJ AUGMENTIN 1.2G IV/TID
T PROMOLET XL 50 MG PO/TWICE DAILY AT 8 AM 8PM
T THYRONORM 75 MCG PO/ONCE DAILY AT 8 AM
TTETRABENAZINE12.5MGPO/THRICEDAILYAT8AM-2PM-8PM LIQUID PARAFFIN L/A TWICE DAILY 8AM 8PM
T TECZINE 5 MG SOS
INJ LASIX 20MG IV/TWICE DAILY 8AM 4PM
SYRUPASCORILLS10MLPERORALTHRICEDAILY GRBS 7.O PROFILE MONITORING
STRICTI/OCHARTING MONITOR VITALS
Advice at Discharge
INJ HAI SUBCUTANEOUS 6U----6U 6U[8AM-1PM-8PM]
TAB ECOSPIRIN -AV 75/20 PO ONCE DAILY AT 8PM
TAB HYDRALAZINE 12.5MG PO ONCE DAILY FOR 1 WEEK AT 8 AM
TAB LASIX 20MG PO/BD FOR ONE WEEK 8 AM 4PM
T PROMET-XL 25 MG PER ORAL TWICE DAILY AT 8 AM 8PM
T THYRONORM 75 MCG PER ORAL ONCE DAILY AT 8 AM
LIQUIDPARAFFINLOCALAPPLICATIONTWICEDAILY[MORNINGANDNIGHT]FOR4WEEKS SYRUP ASCORIL LS 10ML PO TID 8AM-----2PM 8PM
TTECZINE5MGPERORALSOS STRICT DIABETIC DIET
