Dr. Md Rashedul Islam FCPS, MRCP(UK)

Registrar, Neurology, BIRDEM

A 35 years old diabetic right handed lady hailing

from Mirpur, Dhaka got admitted in BIRDEM

General Hospital on 12th November,14

with the complaints of-

• Altered level of consciousness for 12 days

According to the statement of the patient,

she was reasonably well 12 days back. Then she developed altered level of consciousness which was gradual on onset associated with confusion, drowsiness, behavioral changes, difficulty in swallowing & vomiting. It was not associated with fever, headache, loss of consciousness & convulsion.

H/O Present illness

On detailed query she gives history of vomiting for 15 days which was projectile, containing undigested food materials. It was not mixed with blood or bile. It was associated with upper abdominal pain which was burning in nature, mild in severity without any radiation. With the above complaints she was admitted in NIKDU & investigated.

H/O Present illness

CT Scan of brain was done in NIKDU which was normal. Routine blood test was done which showed hyponatremia. She was diagnosed as a case of DMT2 & electrolyte imbalance there & subsequently transferred to Neurology, BIRDEM for further management & treatment.

CT Scan of Brain

H/O past illness: Nothing contributory Socioeconomic history: She belongs to a middle class family

Personal history:

She is non alcoholic, non smoker

Family history:

Nothing significant

Treatment history:

Tab. Metformin

Table salt

I/V 0.9%NaCl during admission in NIKDU

General examination:

Appearance: ill looking, vacant look, NG tube in situ Built: average Decubitus: on choiceAnaemiaJaundiceCyanosisOedemaDehydrationClubbingKoilonychiaLeukonychia

Absent

General examination:

Neck vein: not engorged

Thyroid: not enlarged

Lymph node: not palpable

Skin pigmentation & body hair distribution: normal

Pulse: 86 b/min

BP: 130/80 mmHg

Temp:98 F

RR: 16 breaths/min

• Higher psychic function : Disoriented,

apathetic, decreased responsiveness to external

stimuli. • Speech: Could not be assessed• Cranial nerves : Could not be assessed properly.• Fundus: Normal• GCS: 8/15

NERVOUS SYSTEM EXAMINATION

Muscle Rt. UL Lt. UL Rt. LL Lt. LL

Bulk Normal Normal Normal Normal

Tone Increased Increased

Increased Increased

Power Could not be assessed properly

Involuntary movement

Absent Absent Absent Absent

MOTOR FUNCTION:

Reflex B T S K A Abd Plantar

Right ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ Absent

Extensor

Left ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ Abse

nt

Extensor

Sensory system:

Pain Temp Touch Vibration

Position sense

Right upper limb

Could not be assessed properly

Right lower limb

Left upper limb

Left lower limb

• Sign of Meningeal irritation - Absent

• Cerebellar sign : Could not be assessed properly

• Gait: Could not be assessed properly

Systemic examinations

Other systemic examination was normal

A 35 years old diabetic right handed lady got admitted in BIRDEM General hospital with the complaints of altered level of consciousness for 12 days which was gradual on onset associated with confusion, drowsiness, behavioral changes, difficulty in swallowing & vomiting. It was not associated with fever, headache, loss of consciousness & convulsion.

Salient feature

Salient feature

She also gives history of vomiting for 15 days which was projectile, containing undigested food materials. It was not mixed with blood or bile. It was associated with upper abdominal pain which was burning in nature, mild in severity without any radiation.

Salient feature

On examination ,she was ill looking, NG tube in situ Disoriented, apathetic, decreased responsiveness to external stimuli, GCS 8/15, generalized hypertonia, exaggerated deep tendon reflexes including bilateral extensor planter responses. Other systemic examination was normal

PROVISIONAL DIAGNOSIS

• Diabetes Mellitus Type 2

• Pseudo bulbar palsy due to brainstem stroke

• Electrolyte imbalance

DIFFERENTIAL DIAGNOSIS

• Osmotic demyelination syndrome due to Electrolyte imbalance

• Locked in syndrome

• Brainstem encephalitis

Investigations

CBC:

Hb % - 11.2

WBC -7000 cu/mm

Neu-65 %

Lymph- 17.8 %

Mono -5.9 %

Eosino- 1.1%

Platelet- 195000

ESR- 22mm in 1st hour

S. Electrolytes

S. Electrolyte Value Date

S. Sodum 108mmol/l 1.11.14

S. Sodum 129mmol/l 2.11.14

S. Sodum 145mmol/l 5.11.14

S. Sodum 138mmol/l 9.11.14

S. Sodum 139mmol/l 12.11.14

S. Electrolytes

Na-139 mmol/l

K-4.1 mmol/lCl: 108 mmol/lHCO3: 23 mmol/lCa- 8.9 mmol/lMg- 0.8 mmol/lPhosphate-2.8

Lipid profile:

TG: 136 mg/dl

T. Chol : 122 mg/dl

LDL: 55 mg/dl

HDL: 40 mg/dl

LFT:

ALT: 28 iu/L

AST: 32 iu/L

RFT:

S. Creatinine: 0.9mmol/l

S Urea: 36 mmol/l

Sugar - Nil

Albumin – Nil

Ketone- Nil

Epi. cell: A few /HPF

Pus cell: 1-2 /HPF

RBC: Nil

URINE R/M/E

Chest X-Ray

NORMAL

ECG

Normal

MRI of Brain

MRI of Brain

MRI of Brain

MRI of Brain

MRI of Brain

MRI of Brain

MRI of Brain

Endoscopy of upper GIT:

Erosive antral gastritis

Final diagnosis:

• Diabetes mellitus type 2

• Osmotic demyelination syndrome due to hyponatremia

• Erosive antral gastritis

Treatment:

Short acting insulin

Cap. Omeprazole

Neurorehabilitation

Supportive treatment

Patient was counseled about Course and prognosis of the disease

Follow UP

Patient was advised to follow up in Neurology OPD for further clinical evaluation & management

Acknowledgement :

Department of Physical Medicine