ALTERED SENSORIUM SECONDARY TO HYPOGLYMEIA (RECOVERED) HYPONATREMIA

Case History and Clinical Findings Altered behaviour since1 hr Difficulty in swallowing since 4 days 65 year old female patient non diabetic non hypertensive who is a Telugu tutor at home and was able to do all her house hold works on her own till 2006 then from 2006 she was getting water from step well then she got her hipand knee pains from 2008 where they took to hospital they suggested for surgery but Attendors neglected it because of financial issues then from that time patient was slowly walking from 1 year she started walking with the support(wall) and do her own works then from few days she is walking with walker . Patient had odynophagia since 4 days then she did not take food and on the day of admission she got up in the mrng and was oriented to place time and person then after some time she was not oriented to person since afternoon then they brought patient to the hospital with complaints of Altered behaviour since1 hrDifficulty in swallowing since 4 days Past history : N/K/C/O DM ,HTN, CAD ,Asthma, TB ,seizures O/E : NO Pallor, icterus, cyanosis,clubbing,lymphadenopathy,Edema pt is c/c/c Afebrile PR: 98bpm BP:110/70mmHg RR: 18cpm CVS: S1S2+ RS:BAE+ CNS: Handedness: right handed Consciousness: conscious GCS: E4V5M6 Orientation: oriented to place time and personMemory: Immediate: intact Recent: intact Remote:intact Attention: intact Calculation: intact Cranialnerves: normal Motor system Attitude - lower limbs flexed at knee joint Muscle tone: Right. Left UL N. N LL. N. N Muscle power: UL. 5/5. 5/5 LL 4/5 4/5 Reflexes Right Left Biceps 2+ 2+ Triceps 2+ 2+ Supinator 2+ 2+ Knee - Ankle - Page-3 Platar. Mute ExtendsSuperficial reflexes and deep reflexes are present , normal Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are normal BRIEF COURSE IN HOSPITAL: patient came to opd with the c/o: Altered behaviour since1 hr Difficulty in swallowing since 4 days pt presented with altered behaviour i.e not oriented to place and person due to hypoglycemia (50mg/dl)then 25D was connected where patient grbs levels got increased to 138 from thn patient got oriented to place and person then patient complained of blurring of vision for which ophthamology refferal was taken ophthamology referral: fundocsopy was done impression:no abnormalities in fundal examination noted orthopaedics referral: orthopaedics referral was taken i/v/o: since hass difficulty in walkingsince 2008 and had fixed joints since 5 years L/E: patient is lying in supine position with both hips and knee in flexed position knee right left skin norml niormal swelling (-) (-) local rise of temp (-) (-) crepitus (+) (+) tenderness medial and lateral mediual and lateral joint lines both medial joint line and lateral femoral condyles rom fixed in flexion of 60 deg fixed in flexion 60 degree further flexion of 15degree further flexion of 15deg present and painful present and painful extension absent absentankle movements (+) (+) toe movements (+) (+) sensations (+) (+) distal pulses (+) (+) DIAGNOSIS:GRADE C4 OA B/L KNEE WITH LEFT PROTRUSSION ACETABULI adviced to phsiotherapy
 ENT REFERRAL:
 ent referral was taken for dysphagia and adviced for upper GI endoscopy 
COMPLETE URINE EXAMINATION (CUE) 28-11-2022 01:51:PM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010 ALBUMIN Trace SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-3 EPITHELIAL CELLS 2-3 RED BLOOD CELLSNil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil BLOOD UREA 2811-2022 01:51:PM 14 mg/dl 50-17 mg/dl SERUM CREATININE 28-112022 01:51:PM 0.6 mg/dl 1.2-0.6 mg/dl SERUM ELECTROLYTES (Na, K, C l) 28-11-2022 01:51:PM SODIUM 128 mmol/L 145-136 mmol/L POTASSIUM 3.2 mmol/L 5.1-3.5 mmol/L CHLORIDE 92 mmol/L 98-107 mmol/L T3, T4, TSH 28-11-2022 01:51:PM T3 0.51 ng/ml 1.87-0.87 ng/ml T4 6.81 micro g/dl 12.23-6.32 micro g/dl TSH 1.26 micro Iu/ml 5.36-0.34 micro Iu/ml LIVER FUNCTION TEST (LFT) 28-11-2022 03:26:PM Total Bilurubin 1.01 mg/dl 1-0 mg/dl Direct Bilurubin 0.20 mg/dl 0.2-0.0 mg/dl SGOT(AST) 147 IU/L 31-0 IU/L SGPT(ALT) 145 IU/L 34-0 IU/L ALKALINE PHOSPHATASE 147 IU/L 141-53 IU/L TOTAL PROTEINS 5.9 gm/dl 8.3-6.4 gm/dl ALBUMIN 3.43 gm/dl 4.6-3.2 gm/dl A/G RATIO 1.39 HBsAg-RAPID 2811-2022 03:26:PM Negative Anti HCV Antibodies- RAPID 28-11-2022 03:26:PM Non Reactive HIV 1&2 ELISA 2811-2022 03:26:PM Non Reactive POST LUNCH BLOOD SUGAR 2911-2022 05:51:AM 169 mg/dl 140-0 mg/dl SERUM ELECTROLYTES (Na, K, C l) 29-11-2022 05:51:AM SODIUM 127 mmol/L 145-136 mmol/L POTASSIUM 3.0 mmol/L 5.1-3.5 mmol/L CHLORIDE 93 mmol/L 98-107 mmol/L SERUM ELECTROLYTES (Na, K, C l) 29-11-2022 10:21:PM SODIUM 122 mmol/L 145-136 mmol/L POTASSIUM 2.8 mmol/L 5.1-3.5 mmol/L CHLORIDE 95 mmol/L 98-107 mmol/LABG 30-11-2022 08:47:AM PH 7.47 PCO2 30.4 PO2 78.2 HCO3 22.3 St.HCO3 24.2 BEB-0.2 BEecf-0.8 TCO2 45.5 O2 Sat 95.9 O2 Count 14.1 PHOSPHOROUS 3011-2022 04:30:PM 2.0 mg/dl 4.5-2.5 mg/dl SERUM ELECTROLYTES (Na, K, C l) 01-12-2022 02:33:PM SODIUM 129 mmol/L 145-136 mmol/L POTASSIUM 3.1 mmol/L 5.1-3.5 mmol/L CHLORIDE 91 mmol/L 98-107 mmol/L SERUM ELECTROLYTES (Na, K, C l) 01-12-2022 10:50:PM SODIUM 129 mmol/L 145-136 mmol/L POTASSIUM 2.9 mmol/L 5.1-3.5 mmol/L CHLORIDE 98 mmol/L 98-107 mmol/L URINARY URIC ACID (24 HOURS) 02-122022 08:26:AM 340 MG/DAY MG/DAY
Diagnosis
 ALTERED SENSORIUM SECONDARY TO HYPOGLYMEIA (RECOVERED) HYPONATREMIA
Treatment Given
 1. PLENTY OF ORAL FLUIDS 
2.SYP. POTKLOR 15ML PO/TID 
3.BP MONITORING 4TH HRLY 
4.GRBS MONITORING 
5.INFORM SOS 
Follow Up 
and patient attenders where explained about th patient condition and need for the further stay in the hospital in there own understandable language and but they refuspatiented for further stay and treatment as attenders dont want to stay beside stopping all there work and want to take to hospital near their house hospital staff and doctors are not responsible for any further detoriation of the patients condition

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