A 74 year old woman with Recurrent hypoglycemia and tremors

A 74 year old woman presented to the casualty yesterday

In altered sensorium since morning 10am 

She is an elderly woman, who studied till her 4th grade and has 6 children, 4 sons and 2 daughters. Her husband expired in 1982, according to her son the reason for his father's death

 is not clearly known and it was suspected to be due to suicide because of family issues.  

30 years back she underwent hysterectomy- secondary to ?fibroids 

25 years back on routine check up she was diagnosed to be a Hypertension and diabetic. 

She was started on Tab metxl 50mg along with Tab Galvusmet 50/500mg (vildagliptin along with metformin) 

10 years back she consulted a local doctor for bilateral lower limb edema and was diagnosed with hypothyroid and was started on Tab thyronorm 100mcg which was later made to 50mcg.

6 years back she experienced chest pain along with dyspnea at rest after which she was diagnosed to have TVD and a CABG was performed.

6 years back - she complained of reduced vision in her left eye for which surgery was done. Since the past 3 years she has also been complaining of right

 eye vision.

Since the past 5 to 6 years she has been experiencing tremors of the right upper limb and lower limb along with left upper limb. The tremors are more in her right upper limb and lower limb and are of high amplitude. These tremors according to her son reduce on doing activity but increases when she is at rest and are absent while she is asleep. 

Since the past 5 years she has been living by herself.

3 years back her son took her to his home. He noticed that she stopped getting involved in conversations and it would take her time to understand things.  She would often not respond when questioned. She stopped expressing her emotions. They also noticed the change in her gait. She started walking very slowly.

She was taken to a local hospital for these complaints and was diagnosed with parkinsons disease and was started on Tab Tetrebenazine 25mg OD and Tab Trihexyphenidyl 2mg OD.

3 months back Tab Galvusmet 50/500mg was stopped and she was started on Tab Glimi M2 OD.

Few days later she was found to be hypoglycemic after experiencing giddiness and it was made Tab Glimi M2 half tablet OD 

10 days back, she experienced giddiness again and experienced a fall. 

Since the past few days according to her son and daughter , the patient complained to them on phone that she had fever for 2 days after which she has been having reduced appetite. 

Since 1 day she didn't take their calls after which they got worried and asked her neighbours to check on her and they informed them that she was doing fine.

Today morning at 10am when her son visited her, he saw her laying on her bed with her eyes open. He immediately made her drink water which she swallowed but was not responding and he also noticed that her bed was wet.

Within an hour she was got to our hospital. 

In our hospital her GCS was 3 and her bilateral pupils were reacting to light. 

Her GRBS was found to be 41mg/dl.

Her other vitals were normal. She was started on 25D after which her GRBS rose to 161 mg/dl And her sensorium improved.

Pallor+

MMSE performed showed a score of only 2/30. She is unable to perform registration, recall or calculation. However she is able to recognize her children.

Power in all her limbs are 5/5

Tone is normal 

Reflexes

           Right        Left

B       2+                2+

T       2+                 2+

S       2+                 2+

K       2+                  2+

A        +                    +

P     Withdrawal

Reduced arm swing

Bradykinesia+

Her creatinine is 3.4 and her kidney sizes are reduced. 

HB - 9.8 

Giving a CKD picture

Diagnosis - 

1. Hypoglycemia secondary to OHAs on renal failure 

2. ? Parkinsons disease

3. Known case of HTN and DM type 2 since 25 years

Known case of Hypothyroid since past 10 years

4. Post CABG 6 years back (TVD)

5. Anemia under evaluation