80/Y/M WITH EXCESSIVE SLEEPINESS ,SLURING OF SPEECH ,STIFFNESS OF ALL 4 LIMBS
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PERSONAL HISTORY :
GENERAL EXAMINATION:
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
Diagnosis - True hyponatremia secondary to drug induced with past h/o DM and HTN with anemia under evaluation
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
No meningeal signs
A- Chronic hyponatremia(True hyponatremia) hypovolemia ?SIADH with anemia under evaluation with known case of DM and HTN
P:
1.Head end elevation
2.IVF 3%NaCl @4ml / hr ( to be increased or decreased according to serum electrolytes)
3.RT feeds( 100ml milk+ 100ml free water 2nd hourly)
4.Inj.PANTOP 40mg /IV/OD
5.INJ.NEOMOL 100ml/IV/if Temperature >101.1°f
6.nebulisation with SALBUTOMOL 2 resipules (6th hourly)
7.Oral sectioning 2nd hourly
8.Syrup ASCORYL /RT/ BD
9.INJ.MONOCEF 1gm / IV/ BD
10.TEMPERATURE CHARTING HOURLY
11.BP,PR,SPO2 CHARTING 2ND HOURLY
12.INJ.THIAMINE 2 Amp in 100ml NS/ IV/BD
13.MEGAHEAL ointment for L/A BD
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, no 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
USG ABDOMEN
A- Chronic hyponatremia(True hyponatremia) hypovolemia ?SIADH with anemia under evaluation with known case of DM and HTN
80year old male who is a retired bank manager, residing in ramannapeta survived with 3 kids was brought to casualty with c/o
1. excessive sleepiness since 4 days
2. Unable to identify people since 4days
3. Stiffness of all 4 limbs since 4 days
4. Slured speech since 4 days
HOPI:
1. excessive sleepiness since 4 days
2. Unable to identify people since 4days
3. Stiffness of all 4 limbs since 4 days
4. Slured speech since 4 days
HOPI:
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.
Since 20days patient attender observed loss of appetite, decreased intake of food ,unable to identify the people
No history of head truma
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
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 :
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
BP: 140/90mmhg
PR: 84 bpm
SYSTEMIC EXAMINATION
CVS: muffled heart sounds
RS: NVBS+,B/L wheeze + in ISA,MSA,IAA
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
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%
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
No meningeal signs
A- Chronic hyponatremia(True hyponatremia) hypovolemia ?SIADH with anemia under evaluation with known case of DM and HTN
P:
1.Head end elevation
2.IVF 3%NaCl @4ml / hr ( to be increased or decreased according to serum electrolytes)
3.RT feeds( 100ml milk+ 100ml free water 2nd hourly)
4.Inj.PANTOP 40mg /IV/OD
5.INJ.NEOMOL 100ml/IV/if Temperature >101.1°f
6.nebulisation with SALBUTOMOL 2 resipules (6th hourly)
7.Oral sectioning 2nd hourly
8.Syrup ASCORYL /RT/ BD
9.INJ.MONOCEF 1gm / IV/ BD
10.TEMPERATURE CHARTING HOURLY
11.BP,PR,SPO2 CHARTING 2ND HOURLY
12.INJ.THIAMINE 2 Amp in 100ml NS/ IV/BD
13.MEGAHEAL ointment for L/A BD
DAY: 2
S:excessive sleepiness is decreased ,responding to commands ,fever spikes present
O:General examination: PALLOR +
S:excessive sleepiness is decreased ,responding to commands ,fever spikes present
O: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+
Supinator 2+ 2+
Knee - -
Ankle 2+ 2+
Plantar extension extension
No meningeal signs
A- Chronic hyponatremia(True hyponatremia) hypovolemia ?SIADH with anemia under evaluation with known case of DM and HTN
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+
Supinator 2+ 2+
Knee - -
Ankle 2+ 2+
Plantar extension extension
No meningeal signs
A- Chronic hyponatremia(True hyponatremia) hypovolemia ?SIADH with anemia under evaluation with known case of DM and HTN
P :
1.Head end elevation
2.IVF 3%NaCl @4ml / hr ( to be increased or decreased according to serum electrolytes)
3.RT feeds( 100ml milk+ 100ml free water 2nd hourly)
4.Inj.PANTOP 40mg /IV/OD
5.INJ.NEOMOL 100ml/IV/if Temperature >101.1°f
6.nebulisation with SALBUTOMOL 2 resipules (6th hourly)
7.Oral sectioning 2nd hourly
8.Syrup ASCORYL /RT/ BD
9.INJ.MONOCEF 1gm / IV/ BD
10.TEMPERATURE CHARTING HOURLY
11.BP,PR,SPO2 CHARTING 2ND HOURLY
12.INJ.THIAMINE 2 Amp in 100ml NS/ IV/BD
13.MEGAHEAL ointment for L/A BD
DAY: 3
S:excessive sleepiness is decreased ,responding to commands ,fever spikes present
O:Patent is conscious , Incoherent ,cooperative
BED SORES+
S:excessive sleepiness is decreased ,responding to commands ,fever spikes present
O:Patent is conscious , Incoherent ,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, no 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
A- Chronic hyponatremia(True hyponatremia) hypovolemia ?SIADH with anemia under evaluation with known case of DM and HTN
1.Head end elevation
2.Inj.PANTOP 40mg /IV/OD
3.INJ.NEOMOL 100ml/IV/if Temperature >101.1°f
4.nebulisation with SALBUTOMOL 2 resipules (6th hourly)
5.Oral sectioning 2nd hourly
6.Syrup ASCORYL /RT/ BD
7.INJ.MONOCEF 1gm / IV/ BD( day3)
8.TEMPERATURE CHARTING HOURLY
9.BP,PR,SPO2 CHARTING 2ND HOURLY
10.INJ.THIAMINE 2 Amp in 100ml NS/ IV/BD
11.MEGAHEAL ointment for L/A BD
DAY: 4
S:excessive sleepiness is decreased ,responding to commands , fever spikes present
O:Patent is conscious , coherent ,cooperative
Bed sores +
Temperature:99.1°f
PR - 110bpm
BP - 140 / 90 mmhg
RR: 18cpm
Spo2 g 98%
GRBS - 129gm%
I/O-1500ml/2350ml
CVS - s1 s2 + no murmurs
RS - NABS+ B/L wheeze + ISA,no crepts
P/A - soft, no tender,Distended,everted umbilicus
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 130-135mEq/ml
B/L KNEE X RAY :
A- Chronic hyponatremia(True hyponatremia) hypovolemia ?drug induced with anemia under evaluation with known case of DM and HTN
S:excessive sleepiness is decreased ,responding to commands , fever spikes present
O:Patent is conscious , coherent ,cooperative
Bed sores +
Temperature:99.1°f
PR - 110bpm
BP - 140 / 90 mmhg
RR: 18cpm
Spo2 g 98%
GRBS - 129gm%
I/O-1500ml/2350ml
CVS - s1 s2 + no murmurs
RS - NABS+ B/L wheeze + ISA,no crepts
P/A - soft, no tender,Distended,everted umbilicus
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 130-135mEq/ml
A- Chronic hyponatremia(True hyponatremia) hypovolemia ?drug induced with anemia under evaluation with known case of DM and HTN
P:
1.propped up position
2Inj.PANTOP 40mg /IV/OD
3.INJ.NEOMOL 100ml/IV/if Temperature >101.1°f
4.nebulisation with SALBUTOMOL 2 resipules (6th hourly)
5.Syrup ASCORYL /PO/TID
6.INJ.MONOCEF 1gm / IV/ BD( day4)
7.TEMPERATURE CHARTING HOURLY
8.BP,PR,SPO2 CHARTING 2ND HOURLY
9.INJ.THIAMINE 2 Amp in 100ml NS/ IV/BD
10.MEGAHEAL ointment for L/A BD
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