Thursday, March 3, 2022

59Y/F with hyponatremia

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

A 59Y/F  brought to the casualty with c/o involuntary movements of B/L upper limbs and lower limbs ,GTCS type , with uprolling of eye, tongue bite, involuntary micturition, lasting for 2.min , with post ictal confusion + ,aura -.

H/o vomitings, (4-5 episodes in a day), nonbilious, non projectile, food particle as content

H/o pain abdomen since yesterday diffuse type, 

No c/o cold, cough, fever, burning micturition, headache ,trauma, Loc.


Past history:-N/k/c/o Dm/htn/epilepsy/ CAD/Ba/thyroid disorders.


Personal history:-

Married

Occupation Housewife

Diet  - Mixed,

Appetite -Normal ,

Bowel Movement - Regular 

Bladder movements: Normal

No habit of  addictions

No Known Drug Allergies

Menopause attained


Family History: Not Significant


O/e:

Patient has altered sensorium 

No signs of Pallor, icterus, Cyanosis, Clubbing, Lymphadenopathy,Pedal Edema










Vitals;-

Temp:98m5

Pr:89bpm

Rr:17cpm

Bp:140/80

Spo2:97% at RA

GRBS: 160mg/dl

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender

Cns:-

Patient is conscious but drowsy 

Speech  is incoherent

No signs of meningeal irritation

Cranial nerves- NAD 

Motor system: NAD

Sensory system: NAD

Gcs:- E4V2M6

                           -         RIGHT               LEFT

PUPIL.                    NSRL.               NSRL

TONE         UL        NORMAL       NORMAL

                     LL        NORMAL       NORMAL

POWER    UL         NORMAL       NORMAL

                    LL         NORMAL       NORMAL                    

REFLEXES  

       a) BICEPS               2+                    2+

       b) TRICEPS            2+                    2+ 

       c) SUPINATOR       2+                    2+

       d) KNEE                   2+                    -

       e) ANKLE                 2+                    2+

       f) PLANTAR        extensor          extensor

Investigations:- 

ABG

PH  7.44

PCO2 24.0

PO2 107

HCO3 16.1

ST HCO3 20.0

HEMOGRAM: 

HB: 13.5

TLC: 16,800

N/L/E/M/B: 86/09/01/05/00

PCV: 38.1

MCV: 80.8

MCH: 28.6

RBC:4.72

RDW-CV :12.6

RDW-SD: 41.7

PS: NC/NC

PLT:-1.1

CUE-

Alb :+

Sugars:nil

Pc:4-5/Hpf 

RBS 164mg/dl

SERUM ELECTROLYTES


3/3/22

         8am.     12pm.      6pm.    

Na+   134.    137.         138

K+.     3 3.     3.4.        3.1

Cl-.     107.     97.         97


Blood Urea : 16 MG/DL

Serum Creatinine: 0.7

Serum calcium:10.9

Serum phosphate: 2.4

LFT

TB: 1.35

DB: 0.3

SGOT:19

SGOT:25

ALP: 163

TP:7.6

ALBUMIN:4.9

A/G: 1.87

SER.LIPID PROFILE: 

Total cholesterol:171mg/dl

Triglycerides: 153mg/dl

HDL: 48

LDL:98

VLDL:30

TFT(3/3/22):

T3:0.71

T4;9.10

TSH:4.91

SPOT URINE SODIUM 122

SPOT URINE POTASSIUM 21.0

URINARY CHLORIDE 15

SERUM FOR OSMOLALITY 269

RTPCR: NEGATIVE

SEROLOGY: NEGATIVE

ECG: 



Cxr




2D ECHO:   https://youtu.be/vwqwpJczZvg

TRIVIAL TR+ / AR+ / NO MR

GOOD LV SYSTOLIC FUNCTION + 

NO RWMA , NO AS/MS , SCLEROTIC AV

DIASTOLIC DYSFUNCTION +, NO PAH /PE


USG ABDOMEN:- IMP

Right simple renal cortical cyst

CT BRAIN IMP-No abnormality detected in brain


Diagnosis :- Seizures secondary to hyponatremia


Plan:-

1)Inj. levipril 1 gm in 100ml Ns iv stat

2)inj. pan 40mg iv stat

3)3% Nacl infusion @ 10ml/hr followed by 4th hrly serum electrolytes

4)0.9 % Ns @ 75ml/hr

5)Strict I/O charting

6)Monitor vitals hrly

                                 


                                SOAP NOTES

DAY 1:

Amc Bed 8

Day 1

59yr/F


S: 2 fever spikes  

 

O:

O/e

Patient is c/c/non cooperative

Temp:Afebrile

Pr:89bpm

Rr:17cpm

Bp:120/70

Spo2:97% at RA

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender

CNS: E4V5M6

Pupils : B/l Nsrl

                     RIGHT               LEFT


PUPIL.          NSRL.                NSRL


TONE UL NORMAL        NORMAL


              LL NORMAL        NORMAL


POWER UL NORMAL     NORMAL


                  LL NORMAL     NORMAL                    


REFLEXES  


       a) BICEPS 2+               2+


       b) TRICEPS 2+            2+ 


       c) SUPINATOR 2+       2+


       d) KNEE         -.            -


       e) ANKLE     2+             2+


       f) PLANTAR extensor extensor


Didn't pass stools

GRBS: 100mg/dl


A: Seizures secondary to chronic hyponatremia (hypovolemia- resolved) 


P:

1.Ivf - 3%  Nacl @ 15ml/hr to be I/D A/to sr.electrolytes 4th hrly   

2.inj monocef 1gm/iv/bd

3.inj pan 40mg/iv/od

4.inj zofer 4mg/iv/sos

5.inj neomol 100ml /iv/ if temp > 101.1°F

6.Monitor vitals 2nd hrly

7.Head end elevation upto 30°


6PM:- 

3%Nacl stopped

0.9% Nacl @ 50ml/hr



DAY 2 


Amc Bed 8

Day 2

59yr/F


S: no fever spikes  

 no fresh complaints


O:

O/e

Patient is c/c/c

Temp:Afebrile

Pr:89bpm

Rr:17cpm

Bp:140/90

Spo2:97% at RA

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender

Didn't pass stools

GRBS: 114mg/dl


A: Seizures secondary to chronic hyponatremia (hypovolemia- resolved) 


P:

1.Ivf - 1 Ns with 1 amp of optineuron /iv/od

2.inj monocef 1gm/iv/bd

3.inj pan 40mg/iv/od

4.inj zofer 4mg/iv/sos

5.inj neomol 100ml /iv/ if temp > 101.1°F

6. Syp cremaffin 10ml.tid

7.Monitor vitals 2nd hrly








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