ALTERED SENSORIUM SECONDARY TO ? TRUE HYPONATREMIA

Case History and Clinical Findings 52YEAR OLD MALE CAME WITH THE CHIEF COMPLAINTS OF GIDDINESS SINCE 3 DAYS VOMITINGS 2 DAYS BACK LOOSE STOOLS 2 DAYS BACK INVOLUNTARY MOVEMENTS OF BILATERAL UPPER LIMBS SINCE YESTERDAY MORNING
 HOPI
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED GIDDINESS , SUDDEN IN ONSET , MORE ON STANDING AND LATER PROGRESSED TO GIDDINESS ON SUPINE POSITIONVOMITINGS 2 DAYS AGO 3 TO 5 EPISODES /DAY FOOD PARICLES AS CONTENTS, NON BILIOUS, PROJECTILE AND NON BLOOD STAINED LOOSE STOOLS 2 DAYS AGO ABOUT 3 TO 5 EPISODES PER DAY NON BULKY, NON FOUL SMELLING INVOLUNTARY MOVEMENTS OF HANDS AND FINGERS SINCE MORNING NO H/O LOSS OF CONSCIOUSNESS, UPROLLING OF EYES, INVOLUNTARY MICTURITION OR DEFECATION AND HEADACHE 
PAST H/OK/C/O HTN, SINCE 5 TO 6 YEARS AND ON MEDICATION TELMISARTAN 40 MG PAST H/O CVA PRESENT 2 YEARS BACK NOT A K/C/O DM,TB, ASTHMA, EPILEPSY, THYROID DISORDERS, CVA OR CAD ON 
GENERAL PHYSICAL EXAMINATION-:
PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE ON VITALSBP-- 130/90 MMHG PR- 96 BPM RR- 20 CPM TEMP- 96.8 F SPO2- 975 ON RA GRBS- 117 MG/DL THERE IS NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY AND EDEMA SYSTEMIC EXAMINATION-:
CVS- S1,S2 PRESENT, NO MURMURS
 RS EXAMINATION- BAE PRESENT, POSITION OF TRACHEA -0 CENTRAL, NORMAL VESICULAR BREATH SOUNDS PRESENT 
P/A EXAMINATION- SHAPE OF ABDOMEN- SCAPHOID, BOWEL SOUNDS - PRESENT 
CNS EXAMINATION- HIGHER MENTAL FUNCTIONS - INTACT PUPILS- B/L NORMAL IN SIZE, REACTIVE TO LIGHT SENSORY SYSTEM EXAMINATION-- COULDN'T BE ASSESSED MOTOR SYSTEM EXAMINATIONTONE RIGHT LEFT UPPER LIMB NORMAL NORMAL LOWER LIMB NORMAL NORMAL POWER UPPER LIMB 5/5 5/5 LOWER LIMBS 5/5 5/5 REFLEXES RIGHT - BICEPS - TRICEPS - SUPINATOR - KNEE - ANKLE - PLANTAR- EXTENSION LEFTBICEPS - TRICEPS - SUPINATOR - KNEE - ANKLE - PLANTARS- EXTENSION COURSE IN THE HOSPITAL52YEAR OLD MALE CAME WITH THE CHIEF COMPLAINTS POF GIDDINESS SINCE 3 DAYS VOMITINGS 2 DAYS BACK LOOSE STOOLS 2 DAYS BACK INVOLUNTARY MOVEMENTS OF BILATERAL UPPER LIMBS SINCE YESTERDAY MORNING AND HE WAS TREATED WITH IV FLUIDS 0.9 5 NS T 75 ML/HRINJ. OPTINEURON 1 AMP IN 100 ML NS/ IV/OD INJ. PAN 40 MG IV/OD INJ. METROGYL 500 MG IV/ TID INJ. ZOFER 4 MG IV/ BD TAB. OROFER OZ 200/500 MG PO/OD DAY- 1
C/O SOB AND IRRITABLE BEHAVIOUR STOOLS PASSED YESTERDAY NIGHT INVOLUNTARY MOVEMENTS DECREASED COMPARED TO PREVIOUS DAY AND CONTINUED WITH THE SAME TREATMENT WITH ADDITION OF INJ. CIPROFLOXACIN 200 MG IV/ BD I/V/O INCREASED TLC? INJ. 3 PERCENT NS AT 10 ML/HR NEBULISATION WITH IPRAVENT AND BUDECORT 8TH HOURLY 
DAY-2 
FEVER SPIKE PRESENT YESTERDAY NIGHT STOOLS NOT PASSED INVOLUNTARY MOVEMENTS DECREASED COMPARED TO PREVIOUS DAY AND CONTINUED THE SAME TREATMENT WITH ADDITION OF UDILIV 300MG PO/BD 
DAY 3
 STOOLS NOT PASSED INVOLUNTARY MOVEMENTS DECREASED COMPARED TO PREVIOUS DAY AND CONTINUED THE SAME TREATMENT
 DAY 4 
PATIENT IS CONCIOUS COHERENT AND COOPERATIVE ON VITALSBP-- 130/90 MMHG PR- 96 BPM RR- 20 CPM TEMP- 96.8 F SPO2- 97% ON RAGRBS- 117 MG/DLSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 31-032023 07:36:PMSODIUM132 mEq/L145-136 mEq/LPOTASSIUM3.2 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LCALCIUM IONIZED1.06 mmol/L PATIENT WAS DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION 
Investigation
 MRI REPORT
OLD LACUNAR INFARCT IN LEFT LENTIFORM NUCLEUS 2D ECHOEF- 65% RWSP- 38 MMHG NO RWMA MILD LVH PRESENT TRIVIAL TR/AR PRESENT, NO MR GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION PRESENT, NO PAH/PE IVC SIZE 1.20 CM HEMOGRAM 29/03/23 30/03/23 31/03/23 HB- 13.6 G/DL 12.9 13 TLC-19000 12500 10100 PCV-35.1 33.5 35 RBC-4.67 4.35 4.48 PLT-2.87L 2.38 2.73
Diagnosis
 ALTERED SENSORIUM SECONDARY TO ?TRUE HYPONATREMIA (HYPOVOLEMIC) SECONDARY TO GI LOSSES INVOLUNTARY MOVEMENTS (? POLYMYOCLONUS) SECONDARY TO ? HYPOVOLEMIC HYPONATREMIA[RESOLVED] WITH HTN SINCE 5YEARS
 Treatment Given
 IV FLUIDS 0.9 % NS AT 75 ML/HR
 INJ. OPTINEURON 1 AMP IN 100 ML NS/ IV/OD
 INJ. PAN 40 MG IV/OD 
INJ. METROGYL 500 MG IV/ TID( 4 DAYS) INJ. ZOFER 4 MG IV/ BD INJ. CIPROFLOXACIN 200 MG IV BD X 3 DAYS NEBULISATION WITH IPRAVENT AND BUDECORT 8TH HOURLY
Advice at Discharge
 TAB CIPROFLOXACIN 500MG PO/BD X 2 DAYS 
TAB. METROGYL 400 MG PO/ TID X 2 DAYS TAB PAN 40MG PO/OD/BBF X 1 WEEK
 TAB UDILIV 300MG PO/BD X 1 WEEK
 TAB MVT PO/OD X 1 WEEK 
SYP POTKLOR 10ML PO/TID X 1 WEEK Follow Up 
REVIEW TO GENERAL MEDICINE OPD AFTER 2 WEEKS/REVIEW SOS

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