65 year old female who is illiterate, an agricultural labourer by occupation came with the C/O involuntary movements, giddiness and episodic remote memory loss since 4 months

65 year old female who is an agricultural labourer by occupation came with the C/O involuntary movements, giddiness and episodic remote memory loss since 4 months

Patient was apparently asymptomatic 4 months back 

In the month of August, she had H/O Fever - low grade, intermittent type, associated with generalised weakness which lasted for 3 daysfor which she visited the hospital, fever evaluation was done (dengue ,MP, Widal Negative) and she was prescribed antipyretics for 5 days and the fever subsided within 3 days after medication

After 1 week of fever history, she had right hip pain with tingling sensation of right upper limb and lower limb (upper limb more than lower limb)- associated with sudden outstretching movements of right upper limb associated with tapping of right foot (?hemiballismus).

These involuntary movements were episodic with a frequency of 1 episode per hour, with each episode lasting for 1-2 secs.

Movements were present at rest and increases when patient tries to get up from supine or sitting position.

She also gives the H/O dropping the tea cups while drinking.

These movements were associated with giddiness which was self reeling type.

The movements disappeared on sleeping.

Patient went to the orthopedician for her right hip pain and X-Ray was done which was found to be NORMAL after which she was referred to a neurologist where CT Brain was done which showed OLD CALCIFIED GRANULOMA

The neurologist had started her on:

Tab. Valpraote 300 mg BD

Tab. Gabapin 100 mg OD

Tab. Vitamin D3 PO/OD for 10 days

Tab. Zapiz 0.5 mg PO/HS

Patient attenders gave the H/O abnormal behaviour intermittently,i.e, irrelevant talks ( asking about her grand daughter again and again when she wasn't present over there at that time and also she was assuming that her husband was alive though he had expired in 2005).

As all the above symptoms did not subside till November, the patient again visited the same neurologist again for the above complains and she was started on 

Tab. Queitapine 40 mg 

On 28/11/2021 - 

Patient had a H/O fall due to giddiness and she sustained an injury to her head (head vs bed) leading to a laceration over the left parietal region and a bleed of about 200 ml which was not associated with LOC or seizures -- suturing was done and patient was put on antibiotic.

On 2/12/2021 -

The patient went to the same neurologist after her injury and MRI Brain was done.

MRI BRAIN shows:

1. MILD DIFFUSE CEREBRAL AND CEREBELLAR ATROPHY WITH SMALL VESSEL

2. ISCHAEMIC CHANGES AS DESCRIBED. INCREASED T2 FLAIR SIGNAL INTENSITIES NOTED IN BILATERAL HIPPOCAMPAL REGIONS (LEFT > RIGHT) SHOWING SUBTLE RESTRICTION ON DIFFUSION-S/O

LIKELY NEURO DEGENERATIVE DISEASE ?? METABOLIC ENCEPHALOPATHY

3. SMALL BLOOMING FOCI ON GRE NOTED IN LEFT PARIETAL LOBE AND LEFT

4. OCCIPITAL LOBE WITH NO ADJACENT EDEMA-S/O LIKELY CALCIFIED GRANULOMAS

5. PANSINUSITIS

On 5/12/2021 - 

The patient visited a psychiatrist and she was started on Tab. Escitalopram(10 mg) and Clonazepam(0.5 mg)

Not a K/C/O HTN/DM/Asthma/Epilepsy/TB/CAD/CVA

Family History - Not significant

Personal History-

Diet: mixed

Appetite: normal

Sleep: decreased since 10 days

Bowel and bladder habits: regular

No addictions

General Examination:

Patient is Conscious, coherent, cooperative

Mild pallor +

No icterus/ cyanosis/ clubbing/koilonychia/ lymphadenopathy/ edema

Vitals at admission:

Temp.- Afebrile

BP- 130/80

PR- 69 bpm

RR- 17 cpm

SpO2- 99% @ RA

GRBS- 133 mg/dL

Systemic Examination:

CVS- S1S2 heard, no murmurs

RS- BAE+, NVBS+

P/A- Soft, Non-tender

CNS-

Pt. is C/C/C

Oriented to time, place, person

Speech: Normal

Cranial nerves: Normal

Motor system: Normal

B/L Plantar reflex: Flexion

Sensory system: Normal

MMSE Assessment:

1. Orientation - 4 points

2. Registration - 2 points

3. Attention and calcutation - 5 points

4. Recall - 3 points

5. Language - 

Naming two objects - 2 points

Repeat the phrases - 1 point

Three stage commands - 3 points

6. Copying - 1 point

Total Score - 21 (Mild Cognitive Impairment)

INVESTIGATIONS:

ECG:

PROVISIONAL DIAGNOSIS:

Right hemiballismus with dementia under evaluation

ONGOING TREATMENT:

1. Tab. Queitapine 25 mg PO/OD

2. Tab. Valproate 300 mg PO/OD

3. Tab. VERTIN 16 mg PO/OD

4. Tab. Esihans Plus(Escitalopram(10 mg) and Clonazepam(0.5 mg)) for 15 days