1. Dr. Md Rashedul Islam
FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM
2. 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
3. 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.
4. 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.
5. 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.
7. H/O past illness:
Nothing contributory
Socioeconomic history:
She belongs to a middle class family
Personal history:
She is non alcoholic, non smoker
9. General examination:
Appearance: ill looking, vacant look, NG
tube in situ
Built: average
Decubitus: on choice
Anaemia
Jaundice
Cyanosis
Oedema
Dehydration
Clubbing
Koilonychia
Leukonychia
Absent
10.
11. 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
12. • 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
13. Muscle Rt. UL Lt. UL Rt. LL Lt. LL
Bulk Normal Normal Normal Normal
Tone Increased Increas
ed
Increased Increased
Power Could not
be assessed
properly
Involuntary
movement
Absent Absent Absent Absent
MOTOR FUNCTION:
14. Reflex B T S K A Abd Plantar
Right ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ Abse
nt
Extensor
Left ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑
Abse
nt
Extensor
15. Sensory system:
Pain Temp Touch Vibratio
n
Position
sense
Right upper
limb
Could not be assessed properly
Right lower
limb
Left upper
limb
Left lower
limb
16. • Sign of Meningeal irritation - Absent
• Cerebellar sign : Could not be assessed properly
• Gait: Could not be assessed properly
18. 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
19. 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.
20. 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
24. 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
38. Final diagnosis:
• Diabetes mellitus type 2
• Osmotic demyelination syndrome due to
hyponatremia
• Erosive antral gastritis
39. Treatment:
Short acting insulin
Cap. Omeprazole
Neurorehabilitation
Supportive treatment
Patient was counseled about Course and
prognosis of the disease
40. Follow UP
Patient was advised to follow up in Neurology
OPD for further clinical evaluation &
management