75 YEAR OLD FEMALE WITH TREMORS AND BURNING MICTURITION
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A 75 year old female patient came with chief complaints of
Full body tremors yesterday morning
Burning micturition since 1 week
History of presenting illness:
Patient was apparently asymptomatic till yesterday then she developed sudden onset of shivering in her body for 2 hours after she got up from her bed around 8 am and loss of consciousness while she was still on her bed.
Then she was taken here to the hospital around 4 pm in the evening the same day. Later she had an episode of fits predominantly involving bobbing of her head and flexion of her b/l upper limbs.
She had fever 10 days ago insidious in onset continuous in nature low grade associated with chills
Burning micturition and increased frequency of urination since one week mainly in the night time which didn't relieve on medications.
She had h/o fall while climbing stairs and injury to her right knee 12 years ago, the wound got infected and then she developed non healing ulcer with pus discharge. Skin grafting at that area was done and during this, she got screened and was diagnosed to have diabetes and hypertension and was put on medications on which she has been on it regularly.
She has h/o wrist injury 8-9 years ago.
2 years ago with complaints of weakness and body pains she was taken to a hospital where she was told to have a heart issue and put her on medications.
Past history:
No history of similar complaints on the past
H/o hypertension since 10 years
H/o DM since 12 years
No h/o tb, asthma, epilepsy
Drug history:
Metformin 500mg
Cefixime and OFLOXACIN
Met XL
NODOSIS
Paracetamol, Aceclofenac and Serratiopeptidase
ROSUVASTATIN,CLOPIDOGREL & ASPIRIN
Personal history:
Diet: mixed
Appetite: decreased since 4-5 days
Sleep: disturbed since 3 days
Burning micturition +
Normal bowel movements
No addictions.
General examination:
Patient was conscious cooperative
Oriented to time place and person
Moderately built and nourished
Pallor Icterus cyanosis clubbing lymphadenopathy pedal edema absent.
Temperature: 97.4°C
PR: 88bpm
BP: 130/70
SpO2: 98%
GRBS: 155mg/dl
Systemic examination:
Central nervous system-
Higher mental functions:
Conscious, oriented to time place and person
Speech normal
Memory intact
Cranial nerves -
1 CN: smell perceived
2 CN : visual acuity : CF
Pupil: sluggish pupillary response to light
3,4,6 CN : normal , ocular motility is present in all directions.
5 CN : normal sensory and motor
7 CN : wrinkling on forehead +
Bells phenomenon -
Blow cheeks +
Clench teeth +
8 CN : mild hearing impairment on both sides
9 & 10 CN : gag reflex+ taste sensations+
11 CN- intact
12 CN : tongue movements+ no deviation
Motor system examination
Bulk - normal
Tone-
Right
Upper limb and lower limb Normal
Left
Upper limb and lower limb Normal
Power RT LT
UL 4/5 4/5
LL 4/5 4/5
Reflexes-
Corneal. present
Conjunctival. present
Abdominal. present
Deep reflexes
Biceps + +
Triceps + +
Knee + +
Ankle + +
Sensory examination
Pain +
Temperature +
Pressure +
Vibration+
Fine touch +
Proprioception is lost
cerebellar functions :
Nystagmus : absent
Dysdiadochokinesia : absent
Tandem gait : impaired
Intensional tremors : absent
Rombergs postive
GAIT on the day of admission-
Gait on 24/2/22
https://youtube.com/shorts/RKkvAYgCyq8?feature=share
Respiratory system-
No dyspnea
On inspection-
Shape of chest - bilaterally symmetrical, elliptical
Movement of chest wall - symmetrical, normal anteroposterior
Palpation-
Position of trachea - central
Symmetrical chest expansion
Percussion-
Resonance heard bilaterally in all areas of percussion
Auscultation-
Normal vesicular breath sounds heard in all areas of auscultation
No wheeze
No rhonchi, crepts
Cardiovascular system-
S1 S2 heard. No murmurs and thrills
Abdomen-
Shape - scaphoid
No scars swellings sinuses seen
On palpation-
Non tender, soft, liver spleen not palpable
On auscultation-
Bowel sounds heard
Investigations-
Hemogram:
Hb: 7.6
TLC: 13,600
N: 90
L: 05
Imp: Normocytic hypochromic anemia with neutrophil leukocytosis
Ophthalmology referral
optic disc not visualised due to dense lenticular opacities
ECG
Left ventricular hypertrophy.
USG-
B/l Grade 1 RPD
Doppler 2D echo
MRI brain
Chronic smaller vessel ischaemic changes
Old lacunar infarct in left lentiform nucleus.
Diagnosis-
Myoclonic jerks with altered sensorium 2° to PCA stroke?
Treatment-
1. Inj. PAN 40mg IV/OD
2. Inj. THIAMINE 2amp in 100ml NS/IV/TID
3. Inj. LEVIPILL 500mg IV/BD
4. Inj. MONOCEF 1gm/IV/BD
5. IVF NS& RL
6. BP,PR and temperature 4th hourly monitoring
(24/2/22)
In the view of anemia, the following investigations were sent
Serum ferritin: 113.4
Retic count: 1.3%
Corrected Reticulocyte count: 0.798 calculated using formula Retic count* Pt HCT/Normal HCT.
Impression: hypoproliferative marrow.
Peripheral smear: Normocytic Normochromic RBCs with few microcytes. WBCs increased on smear and platelets adequate.
Low Retic count here could point towards anemia of chronic disease or renal failure, in this context.
Sr.Na+ 128meq/l - hyponatremia
Impression-
Hypo osmolar hyponatremia
LFT:
Tb: 0.54
Db: 0.20
AST: 54
ALT:33
AlkP:126
TP:5.3
Alb: 3.4
A/G: 1.83
25/2/22-
Right knee pain and swelling+
Local examination : swelling + with local rise of temperature + tenderness +
Patellar tap felt
Bursitis?
Burning micturition+
Cue
i/v/o burning micturition
Pus cells : 3-4
Epithelial cells :2-3
Alb : trace
X ray of right knee was taken-
Treatment-
Inj. LEVIPILL 500mg IV/BD
TAB. NEUROKIND PO/ OD
tab metformin 500mg OD
Tab. Clinidipine 10 mg po / OD
BP,PR and temperature 4th hourly monitoring
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