80 YR OLD MALE WITH EXCESSIVE SLEEPINESS , SLURRING OF SPEECH & STIFFNESS OF ALL 4 LIMBS

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box."

 An 80year old male who is a retired bank manager, residing in Ramannapeta survived with 3 kids was brought to casualty with

CHIEF COMPLAINTS :- 

  •   excessive sleepiness since 4 days
  •  Unable to identify people since 4days.     
  •   Stiffness of all 4 limbs since 4 days
  • -Slurred speech since 4 days.

HISTORY OF PRESENT ILLNESS :-

- patient was apparently normal 3 months back then he had observed blackish discoloration of right 4th toe ,for which he was advised amputation of 4th toe and was operated.


- 20 days back he developed B/L swelling of both knees ,for which he was taken to a near by hospital and was given conservative management. 
                                                       ðŸ —

- Since 20days patient attender observed loss of appetite, decreased intake of food ,unable to identify the people
                                                                                                               ðŸ —

- No history of head trauma 
 
- No history of headache

 -No history of seizures 

 -No history of nausea and vomiting

PAST HISTORY:
k/c/o HTN since 30 years and DM since 10years and on regular medication
K/c/o Arthritis since 10 years 


PERSONAL HISTORY : 

  • Diet : Mixed 
  • Appetite : reduced 
  • Sleep - increased 
  • Bowel and bladder movements - increased
  • Allergies : No 
  •  Addictions :- Alcoholic [daily 90ml ] last intake two days back

GENERAL EXAMINATION:

 PALLOR +
No ICTERUS ,CYANOSIS, KAILONYCHIA, LYMPHADENOPATHY, EDEMA

- Patient is drowsy,incoherent, cooperative

          Afebrile
          BP: 140/90mmhg
          PR: 84 bpm

SYSTEMIC EXAMINATION :

    CVS: muffled heart sounds

     RS: NVBS+,B/L wheeze + in ISA,MSA,IAA

PA: Distended,everted umbilicus ,soft ,non tender
CNS:
  Pupils - pseudophakia + B/L
  Tone : Rt Lt
           UL increased increased
           LL increased increased
  Power: 
           UL 2/5 2/5
           LL 2/5 2/5
   Hand grip: 30% 30%
   Reflexes:
       Biceps 2+ 2+
       Triceps 2+ 2+
    Supinator 2+ 2+
       Knee - -
      Ankle 2+ 2+
      Plantar extension extension
No meningeal signs

INVESTIGATIONS:- 








DIAGNOSIS - True hyponatremia secondary to drug induced with past h/o DM and HTN with anemia under evaluation

PLAN:
1. Head end elevation upto 30°
2. IVF - 3% NaCl @ 4ml/hr to be increased or decreased according to electrolytes
3. INJ PAN 40mg /IV/OD
4. INJ NEOMOL 100ml ( if temperature >101.1°f )
5.INJ.THIAMINE 1amp in 100ml NS/IV/BD
6. RT feeds 100ml milk and 100ml free water 2nd hrly
7.vitals monitoring 

DAY 1 :-
  • S:excessive sleepiness ,drowsy ,fever spikes present

  • O:Patent is drowsy
  • Temperature:101.9°f
  • PR - 101 bpm
  • BP - 140 / 90 mmhg
  • Spo2 g 98%
  • GRBS - 97 gm%
  • General examination: PALLOR +
  • No ICTERUS, CLUBBING, CYANOSIS, KAILONYCHIA 
  • GENERALIZED EDEMA +



CVS - s1 s2 + no murmurs

RS - NABS+ B/L wheeze + ISA,MSA,IAA

P/A - Distended, everted umbilicus ,soft, no tender,

CNS - GCS: E3V4M4

Pupils - pseudophakia + B/L

  Tone : Rt Lt
           UL increased increased
           LL increased increased

  Power: 
           UL 3/5 3/5
           LL 3/5 3/5

   Hand grip: 30% 30%

   Reflexes:
       Biceps 2+ 2+
       Triceps 2+ 2+
    Supinator 2+ 2+
       Knee - -
      Ankle 2+ 2+
      Plantar extension extension
meningeal signs

A- Chronic hyponatremia(True hyponatremia) hypovolemia ?SIADH with anemia under evaluation with known case of DM and HTN
P:
.Head end elevation
  • .IVF 3%NaCl @4ml / hr ( to be increased or decreased according to serum electrolytes)
  • .RT feeds( 100ml milk+ 100ml free water 2nd hourly)
  • .Inj.PANTOP 40mg /IV/OD
  • .INJ.NEOMOL 100ml/IV/if Temperature >101.1°f
  • .nebulisation with SALBUTOMOL 2 resipules (6th hourly)
  • .Oral sectioning 2nd hourly
  • .Syrup ASCORYL /RT/ BD
  • .INJ.MONOCEF 1gm / IV/ BD
  • .TEMPERATURE CHARTING HOURLY
  • .BP,PR,SPO2 CHARTING 2ND HOURLY
  • .INJ.THIAMINE 2 Amp in 100ml NS/ IV/BD

DAY 2 :- 
  • S:excessive sleepiness is decreased ,responding to commands ,fever spikes present

  • On General examination: PALLOR +
  • No ICTERUS, CLUBBING, CYANOSIS, KAILONYCHIA
  • GENERALIZED EDEMA +
  • Patent is conscious , incoherent ,cooperative
  • Temperature:99.1°f
  • PR - 97 bpm
  • BP - 140 / 90 mmhg
  • Spo2 g 98%
  • GRBS - 132 gm%
  • CVS - s1 s2 + no murmurs
  • RS - NABS+ B/L wheeze + ISA,MSA,IAA
  • P/A - soft, no tender
  • CNS - patient is drowsy 
  • Pupils - pseudophakia + B/L
  Tone : Rt Lt
           UL increased increased
           LL increased increased
  Power: 
           UL 3/5 3/5
           LL 3/5 3/5
   Hand grip: 30% 30%
   Reflexes:
       Biceps 2+ 2+
       Triceps 2+ 2+

Chronic hyponatremia(True hyponatremia) hypovolemia ?SIADH with anemia under evaluation with known case of DM and HTN 
P :
  • .Head end elevation
  • .IVF 3%NaCl @4ml / hr ( to be increased or decreased according to serum electrolytes)
  • .RT feeds( 100ml milk+ 100ml free water 2nd hourly)
  • .Inj.PANTOP 40mg /IV/OD
  • INJ.NEOMOL 100ml/IV/if Temperature >101.1°f
  • nebulisation with SALBUTOMOL 2 resipules (6th hourly).Oral sectioning 2nd hourly
  • .Syrup ASCORYL /RT/ BD
  • INJ.MONOCEF 1gm / IV/ BD
  • TEMPERATURE CHARTING HOURLY
  • BP,PR,SPO2 CHARTING 2ND HOURLY
  • .INJ.THIAMINE 2 Amp in 100ml NS/ IV/BD
  • MEGAHEAL ointment for L/A BD

DAY 3 :-
  • :excessive sleepiness is decreased ,responding to commands ,fever spikes present

  • O:Patent is conscious , coherent ,cooperative 
  • Bed sores +
  • Temperature:99.1°f
  • PR - 116bpm
  • BP - 130 / 90 mmhg
  • RR: 18cpm
  • Spo2 g 98%
  • GRBS - 129gm%

CVS - s1 s2 + no murmurs

RS - NABS+ B/L wheeze + ISA,MSA

P/A - soft, non tender

CNS - E4V5M6

Pupils - pseudophakia + B/L

  Tone : Rt Lt
           UL increased increased
           LL increased increased
  Power: 
           UL 3/5 3/5
           LL 3/5 3/5
   Hand grip: 30% 30%
   Reflexes:
       Biceps 2+ 2+
       Triceps 2+ 2+
    Supinator 2+ 2+
       Knee - -
      Ankle 2+ 2+
      Plantar extension extension
No meningeal signs

Serum Na+ increased 130-132 mEq/ml

- Chronic hyponatremia(True hyponatremia) hypovolemia ?SIADH with anemia under evaluation with known case of DM and HTN










 
 







 


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