Reflection: Triple Flexion

A 63-year-old woman collapsed in coma while shopping and was brought to the hospital. Additional history obtained from the family by phone revealed that she was taking insulin for adult onset diabetes and a thiazide diuretic for hypertension, but was otherwise well.

On examination, the blood pressure was 170/90, pulse 84/min, and temperature 99.6. Respirations were Cheyne-Stokes but somewhat irregular at 16/min. The pupils were pinpoint, but appeared to be minimally reactive when viewed with a hand lens and a bright light. There was no eye movement, either in response to passive head turning, or to irrigating the external auditory canals with ice water. The extremities were flaccid with symmetrical DTRs of normal amplitude. Plantar stimulation caused flexion at the hip, knee, and ankle (triple flexion) as well as dorsiflexion of the great toe.

Blood was drawn for routine analysis and she was given intravenous glucose without any change in her condition.

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