ALTERED SENSORIUM SECONDARY TO HYPONATREMIA EUVOLEMIC ? SIADH ? WITH HYPOKELEMIA WITH SMALL HEMORRHAGIC CONTUSION FRONTAL LOBE WITH AKI ( RESLOVING ) WITH HYPERTENSION SINCE 4 YEARS,WITH TYPE 2 DIABETES SINCE 18 YEARS

Case History and Clinical Findings 
A 60 YEAR OLD MALE WAS BROUGHT TO CASUALITY IN ALTERED SENSORIUM SINCE YESTERDAY NIGHT PATIENT WAS APPARENTLY ASYMPTOMATIC 10YEARS BACK THEN HE DEVELOPED DM-2 SIMILAR EPISODE THEN HE DIAGNOSED TO HAVE DM-2 AND STARTED ON OHA LATER AFTER FEW YEARS PATIENT WAS SHIFTED TO INSULIN 4YEARS BACK PATIENT DEVELOPED GIDDINESS AND WHILE WORKING PT HAF FALL, FRACTURE RT UL &RT LL, DIAGNOSED WITH HTN ( ON TAB.METOSARTAN CH50, METOPROLOL 50, TELMA 40 ) 2 YEARS BACK PT DEVELOPED SIMILAR COMPLAINTS OF ALTERED SENSORIUM AND WAS HAVING HYPERGLYCEMIA AT PRIVATE HSPTL THEN WAS DIAGNOSED TO HAVE ? DKA ; -GIVEN INSULIN AND TREATEDAFTER THAT;10 DAYS BACK PATIENT DEVELOPED SWELLING OF LOWER LIMBS AND ULCERATION ON RT TOE AND PLANTAR ASPECT OF FOOT FOR WHICH HE WENT TO PUT PRACTITIONER AND DIAGNOSED TO HAVE DIABETIC FOOT AND WAS TREATED WITH REGULAR DRESSINGS AND ANTIBIOTICS LATER 4 DAYS BACK PATIENT DEVELOPED NAUSEA , VOMITING - 2 EPISODES / DAY ASSOCIATED WITH FOOD INTAKE. FOOD PARTICLES AS CONTENT, NOT BLOOD TINGED, 10 MINS AFTER FOOD INTAKE NO H/O FEVER,COLD, COUGH, PAIN ABDOMEN, LOOSE STOOLS, BODY PAINS NOT A K/C/O ASTHMA,CAS,TB,EPILEPSY,CVA O/E : PT IS CONSCIOUS, COHERENT, COOPERATIVE NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LY,PHEDENOPATHY, EDEMA TEMP: 98.9 F PR: 86/MIN BP: 130/80 MM HG CVS : S1, S2 +, NO ADDED SOUNDS JVP NOT RAISED RS : BAE + , NVBS P/A : SOFT, NT, BS + CNS : GCS - E4 V5 M6 NO MENINGIAL SIGNS HMF INTACT POWER : RT - UL : 5/5, LL : 5/5 LT - UL : 5/5, LL : 5/5 TONE : RT - UL : N, LL : N LT - UL : N, LL : N REFLEXES : B T S K A PLANTAR RT : + + + + + FLEXION LT : + + + + + FLEXION
Course in the hospital
The patient got admitted with above mentioned complaints. At the time of admission the patient is drowsy arousable to deep pain not oriented to time place and person patient in altered sensorium on investigating found to have serum osmolality-258 Na-108 and K-2.1 was treated with 3%Ns ,the next day the patient is conscious and still drowsy with Na-115 k-2.2 sr.creat1.9. Diagnosed as altered sensorium with hypotonic hyponatremia euvolemic ?siadh with small hemorrhagic confusion in frontal lobe. Urine osmolality -107mosm Na-123 K-2.8 cr-1.9 urea-70 patient is conscious. Na-130 k-3.1 urea-48 creat-1.7 patient is conscious coherent and cooperative ABGpH 7.53Pco2-27.8Po2-6.50Hco3-23.6Urinary Na- 155K-19.3Cl-122 Volume 1900UNa-213Uk-12.9Ucl- 220Creat-0.40Protein-774Ca2+-58Uric acid-570Referred to General surgery in view of right diabetic toe. Lateral debridement and cuticle dressing with antiseptic dressing is doneMRI BRAIN- small hemorrhagic contusion in right frontal lobeReferred to neurosurgery In view of small hemorrhagic contusion in right frontal lobe and was suggested to continue same treatment Referred to ophthalmologist in view of increased ICT features. Fundus showed no raised ICT features
 Investigation
 HEMOGRAM HB-11.1 TLC-16800 PLT-2.0 PCV-28.5 MCH-28.7 MCHC-38.9 MCV-73.6 RBC-3.87 25/12/2022 HB-11.3 TLC-12,300 PLT-2.0 PCV-28.9 MCH-29.4 MCHC-39.1 MCV-75.3 RBC-3.826/12/2022 HB-10.7 TLC-13000 PLT-2.39 RBC-3.68 USG ABDOMEN : RIGHT SIMPLE RENAL CORTICAL CYSTS MRI BRAIN PLAIN : SMALL HEMORRHAGIC CONTUSION IN RIGHT FRONTAL LOBE 2D ECHO REPORT : NO RWMA, CONCENTRIC LVH + ( 1.30 CMS ) TRIVIAL TR +/ AR + ; NO MR SCLEROTIC AV , NO AS/MS , IAS - INTACT EF = 60, RVSP = 35 MM HG GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION + , NO PE IVC SIZE ( 1.39 CMS ) 
Diagnosis 
ALTERED SENSORIUM SECONDARY TO HYPONATREMIA EUVOLEMIC ? SIADH ? WITH HYPOKELEMIA WITH SMALL HEMORRHAGIC CONTUSION FRONTAL LOBE WITH AKI ( RESLOVING ) WITH HYPERTENSION SINCE 4 YEARS,WITH TYPE 2 DIABETES SINCE 18 YEARS
Treatment Given
 IVF - 3 % NS @ 20ML/HR
 INJ. ZOFER 4 MG/IV/TID 
INJ.KCL 1 AMP + 100 ML NS SLOWLY OVER 2-3 HRS
 INJ.HAI S/C TID ACC TO SLIDING SCALE INJ. MONOCEF 2G/IV/BD 
INJ. PAN 40 MG IV/OD RT FEEDS 100 ML WATER HRLY& 100 ML MILK 2ND HRLY &COCONUT WATER 50 ML/BD SYP.POTCHLOR 15 ML PO/TID 
INJ. PAN 40 MG /IV/OD 
TAB. ALDACTONE 25 MG/PO/BD TAB.NICARDIA 10 MG PO/STAT TAB. TOLVAPTAN 15 MG/PO/ODSTRICT HRLY URINE OUTPUT MONITORING 
TAB.TELMA 40 MG PO/BD 
TAB.MET XL 25 MG PO/BD 
Advice at Discharge 
TAB.MERTFORMIN 500MG PO/BD TAB.GLIMIPERIDE 1MG PO/BD 
TAB.TELMA 40 MG PO/BD 
TAB.MET XL 25 MG PO/BD 
SYP.CREMAFFIN 20ML PO/HS 
Follow Up
 REVIEW TO MEDICAL OPD ON FRIDAY / SOS

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