66 year old female with hemiballismus secondary to uncontrolled sugars

 DOA 22/5/23


A 66 yr old female ,residence of nalgonda came to the opd with c/o 


Slurring of speech since 15days


Involuntary movements of right upper limb since 10days


And right lower limb since 5 days



She was apparently asymptomatic 15days ago then she developed swelling of tongue f/b slurring of speech , insidious in onset and gradually progressive,no aggravating and relieving factors


Not associated with deviation of mouth 



C/o involuntary movements of right upper and lower limb,insidious in onset and gradually progressive , aggravating on increasing sugars and decreasing with decrease in grbs levels



She also c/o skin lesions over genital region since 15days



Past history:


K/c/o HTN since 2 years


K/c/o DM since one week 


She has h/o joint pains( shoulder and elbow) since 2-3 months for which she went to a local hospital and the reports shower RA FACTOR+ 


and was advised tab . methotrexate (on regular medication)




Personal history:


Diet :mixed 


Appetite:normal 


Bowel and bladder:regular but c/o burning micturition since 1 month


Sleep: adequate




Family history:not significant



General examination:


She is conscious,coherent , cooperative 


Well oriented to time ,place and person 


Vitals:

Temp:98.6F

Bp:120/70mmofhg

PR:118bpm

RR:20cpm

Grbs:339mg/dl

No pallor ,icterus ,clubbing ,cyanosis ,lymphadenopathy and edema 



CVS:s1s2+,no murmur

RS:BAE+,no added sounds 

P/A: 
Inspection;

Shape of abdomen; obese 



Position of umbilicus: central and inverted

No scars and sinuses are present

All quadrants are moving equally with respiration





Palpation:

No tenderness

 No organomegaly





Auscultation:

Bowel sounds heard 

 
CNS:
Motor system:RIGHT b                    LEFT.l  Left          
 
Tone :UL:            N.                                        N
            LL:           N.                                         N

Power:UL:          4/5                                     4/5
            LL:           3/5                                     4/5





Obg referral taken I/v/o reddish skin lesions over vulva and inner groin region,white discharge since 15days.

Diagnosis: 66year old p5L5 post hysterectomised with DM 2 and HTN with genital lesions

Advised :
1.inj.ceftrioxone 1gm iv stat f/b Tab.erythromycin 500mg po/BD
2.T.pantop 40mg po/OD
3.T.metronidazole 400mg po/TID 
4.Antibiotic dosage can be escalated or deescalated after swab c/s report 

Dvl referral taken I/v/o genital ulcer :
Diagnosis:Genital ulcer for evaluation+vulvo vaginal candidiasis 

Advised :
1.clotrimazole 1%cream L/A BD for 1 week
2.Tab.BACT ointment L/A BD for 1 week 

Review referral:
Diagnosis:Genital ulcer for Evaluation
?Frictional ulcer 
?herpes genitalis + vulvovaginal candidiasis

Advised:
1.1.clotrimazole 1%cream L/A BD for 1 week
2.Tab.BACT ointment L/A BD for 1 week 
3.continue same treatment as advised by physician 

Opthalmology referral taken I/v/o HTN and DM retinopathy changes :
Impression: no diabetic and HTN retinopathy changes noted in both eyes.

Provisional diagnosis:

Right Hemiballismus secondary to ?Type II DM ?Basalganglia lesion 
Hypokalemia Secondary to 
?GI Losses ?Nutritional 
Genital ulcer for Evaluation
?Frictional ulcer 
?herpes genitalis + vulvovaginal candidiasis
K/c/o HTN 2yrs 
Denovo DM-II (one week)

Investigations: 




















Serology :negative

Chest xray:

ECG:-



USG abdomen:
2decho:



Treatment:

IVF NS and RL @75ml/hr
Inj.optineuron 1amp in 100ml Ns /iv/OD
Tab .amlodipine 5mg po/OD
Tab.tetrabenzine 25mg/poBD
Tab.metrogyl 400mg/po/TID
Tab.pan 40Mg po/OD
Tab.sporolac-Ds po/TID
Inj.HAI sc/TID acc to grbs
Syp.potklor 10ml/po/BDwith glass of water
T.bact ointment for LA /BD
Clotrimazole 1%cream LA/BD
Capsule redotil 100mg po/BD

Advice at discharge:





Obg referral taken I/v/o reddish skin lesions over vulva and inner groin region,white discharge since 15days.

Diagnosis: 66year old p5L5 post hysterectomised with DM 2 and HTN with genital lesions

Advised :
1.inj.ceftrioxone 1gm iv stat f/b Tab.erythromycin 500mg po/BD
2.T.pantop 40mg po/OD
3.T.metronidazole 400mg po/TID 
4.Antibiotic dosage can be escalated or deescalated after swab c/s report 

Dvl referral taken I/v/o genital ulcer :
Diagnosis:Genital ulcer for evaluation+vulvo vaginal candidiasis 

Advised :
1.clotrimazole 1%cream L/A BD for 1 week
2.Tab.BACT ointment L/A BD for 1 week 

Review referral:
Diagnosis:Genital ulcer for Evaluation
?Frictional ulcer 
?herpes genitalis + vulvovaginal candidiasis

Advised:
1.1.clotrimazole 1%cream L/A BD for 1 week
2.Tab.BACT ointment L/A BD for 1 week 
3.continue same treatment as advised by physician 

Opthalmology referral taken I/v/o HTN and DM retinopathy changes :
Impression: no diabetic and HTN retinopathy changes noted in both eyes.

Treatment:

IVF NS and RL @75ml/hr
Inj.optineuron 1amp in 100ml Ns /iv/OD
Tab .amlodipine 5mg po/OD
Tab.tetrabenzine 25mg/poBD
Tab.metrogyl 400mg/po/TID
Tab.pan 40Mg po/OD
Tab.sporolac-Ds po/TID
Inj.HAI sc/TID acc to grbs
Syp.potklor 10ml/po/BDwith glass of water
T.bact ointment for LA /BD
Clotrimazole 1%cream LA/BD
Capsule redotil 100mg po/BD


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