80 YR OLD MALE WITH EXCESSIVE SLEEPINESS , SLURRING OF SPEECH & STIFFNESS OF ALL 4 LIMBS
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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.
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- Since 20days patient attender observed loss of appetite, decreased intake of food ,unable to identify the people
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- 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
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
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:-
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 +
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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