60 year female with altered sensorium secondary to dyselectrolytemia
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I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history , clinical findings , investigations and come up with diagnosis and treatment plan .
CHIEF COMPLAINTS:
Vomiting since 4 days
Generalised weakness since 4 days
Facial puffiness since 3 days
Decreased urine output since 3 days
HOPI :
Patient was apparently asymptomatic 4 days ago, then she had vomitings 3-4 episodes/day , food as content,non projectile , non bilious associated with abdominal pain .
Facial puffiness and decreased urine output since 3 days.
Cough since 4 years , on and off, productive ,scanty white coloured sputum with no diurnal variation, more during winter season.SOB of grade 2 since 4 years more in supine position and during winter .
Burning micturition and decreased stream of urine since 4 days.No C/O hesitancy , dribbling.
No H/O orthopnea, PND, chest pain.
PAST HISTORY:
Not a k/c/o DM , HTN , epilepsy, asthma , CAD , CVD,TB
Hysterectomy 20 years ago.
PERSONAL HISTORY:
Appetite-Decreased
Diet - Mixed
Bowel - Regular
Bladder - burning micturition and decreased stream of urine.
Sleep - Decreased.
General examination:
Patient is conscious, coherent, cooperative, well oriented to time , place and person
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy- absent
Pedal edema - pitting type extending till knee
VITALS : Temp - 98.6 F
PR - 94 bpm
BP - 120/70 mmhg
RR - 18 cpm
SPO2 - 98% onRA
GRBS - 102 mg/dl
Systemic examination:
CENTRAL NERVOUS SYSTEM:on the day of presentation
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes Right Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
CNS examination - on 11/1/23.
GCS - E2 V3 M4
Right. Left.
TONE
UL. HYPOTONIA HYPOTONIA
LL HYPOTONIA. HYPOTONIA
POWER
UL. 2/5. 2/5
LL. 2/5. 2/5
REFLEXES
BICEPS - NEGATIVE NEGATIVE
TRICEPS- NEGATIVE. NEGATIVE
SUPINATOR-NEGATIVE. NEGATIVE
KNEE - NEGATIVE. NEGATIVE
ANKLE NEGATIVE. NEGATIVE
BABINSKI MUTE. MUTE
CNS EXAMINATION ON 12/1/23:
GCS - E4 V5 M6
Right. Left.
TONE
UL NORMAL. NORMAL
LL . NORMAL NORMAL
POWER
UL. 5/5. 5/5
LL. 5/5 5/5
REFLEXES
BICEPS - 1+ 1+
TRICEPS- 1+. 1+
SUPINATOR-1+. 1+
KNEE - 1+. 1+
ANKLE . 1+. 1+
BABINSKI FLEXION. FLEXION
PER ABDOMEN:
Inspection :
Umbilicus is central and inverted
All quadrants are moving equally with respiration
No scars , sinuses , engorged veins, visible pulsations .
Hernial orifices are free.
Palpitation :
Abdomen is soft and non tender .
No organomegaly.
Percussion :
Tympanic note heard over the abdomen.
Auscultation:
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest is elliptical.
No raised JVP
No visible pulsations, scars , sinuses , engorged veins.
Palpitation:
Apex beat - felt at left 5th intercostal space
No thrills and parasternal heaves
Auscultation :
S1 and S2 heard.
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
INVESTIGATIONS:
Hb – 8.4 gm/dl
TLC – 5900 cells/cu mm
Neutrophils : 77
Lymohocytes : 12
Eosinophils : 01
Monocytes : 10
Platelets – 2.14 lakhs/cu mm
CUE :
Albumin - traces
Pus cells - 2-3/HPF
Epithelial cells - 2-3/HPF
RENAL FUNCTION TESTS :
Urea : 24 mg/dl
Creatinine : 1.6 mg/dl
Sodium : 96 mEq/L
Potassium : 1.8 mEq/L
Chloride : 60 mEq/L
LIVER FUNCTION TESTS :
Total bilirubin : 1.54 mg/dl
Direct bilirubin : 0.38 mg/dl
AST : 116 IU/L
ALT : 46 IU/L
Alkaline phosphate :162 IU/L
Total proteins :5.6 gm/dl
Albumin : 3.6 gm/dl
A/G ratio : 1.81
Serum osmolality : 192.4
On 8/1/23:
On 10/1/23:
Morning:
Evening:
On 11/1/23:
On 12/1/23:
Serum calcium : 9.2
Serum phosphorus:3.5
Serum magnesium:1.7
24hr urine sample : volume - 3800 ml
Calcium - 228 mg/day
Sodium -646 mmol/day
Chloride - 532 mmol/day
Phosphorus- 0.30gm/day
Spot urine protein :8
Spot urine creatinine :14.1
Ratio : 0.55
CXR : on the day of admission
On 10/1/23:
ECG :on the day of admission
USG :
TROUSSEAU’s SIGN :
PROVISIONAL DIAGNOSIS:
ALTERED SENSORIUM SECONDARY TO HYPONATREMIA HYPOKALEMIA HYPOCHLOREMIA HYPOCALCEMIA WITH TETANY RESOLVED.METABOLIC ALKALOSIS WITH CHRONIC COUGH (SINCE 4 YEARS)WITH NORMAL CHEST X RAY WITH POSTURAL DROP ?ADDISONS DISEASE ?ADRENAL KOCHS ?ENDOBRONCHIAL KOCHS WITH PRERENAL AKI -RESOLVED WITH
TREATMENT:
INJ 3%NACL 10ml/hr IV
IVF 500 ml NS +2 AMP KCL OVER 5 hrs
INJ ZOFER 4mg IV/BD
INJ PAN 40 mg IV/OD
IVF 0.9 %NACL @ 75 ml/hr
INJ CIPROFLOXACIN 400 mg IV/BD
SYP LACTULOSE 15ml PO/HS
T.OLANZAPINE 2.5 mg PO/BD
T.OROFER XT PO/OD
INJ CALCIUM GLUCONATE 6 AMPOULES IN 500 ml NS@40 ml/hr
T VIT D3 60k ONCE WEEKLY
T PHOSPHORUS 40 mmol/ day
I/O CHARTING
MONITOR VITALS HRLY
BRIEF COURSE IN HOSPITAL:
On 7/1/23 :PATIENT WAS LETHARGIC AT THE TIME OF PRESENTATION. Na- 96 , K -1.8 , cl - 60mEq/lit PATIENT WAS STARTED ON 3%NACL @ 10ml/hr AND 2 AMPOULES OF KCL IN 500 ML NS AROUND 8.30 PM.OBG CONSULTATION WAS TAKEN I/V/O CYSTOCOELE.PACKING WAS DONE.
On 8/1/23:PATIENT WAS ORIENTED TO TIME ,PLACE,PERSON .Na - 110 , K-1.8 , Cl - 683% NACL WAS STOPPED AT 9PM2 AMPOULES OF KCL IN 500 ML NS IS GIVEN ABG : PH -7.57 PCO2 - 39.3 PO2 -78.8 HCO3-36.9
On 9/1/23:PATIENT WAS ORIENTED TO TIME,PLACE,PERSON IN THE MORNING . Na -123 K- 2.2 Cl-802 AMPOULES OF KCL IN 500 ML NS IS GIVENPATIENT DEVELOPED ALTERED BEHAVIOUR FROM 1Pm (SELF TALKING).PSYCHIATRY OPINION WAS TAKEN AND PATIENT WAS GIVEN T. OLANZEPINE 2.5 mgNa -130 K-2.8. Cl-90ABG : PH -7.55 PCO2 - 38.8 PO2 -79.6. HCO3-34.3
On 10/1/23:PATIENT WAS DROWSY FROM MORNING Na - 133. K- 3.3. Cl- 96PATIENT WAS GIVEN INJ HALOPERIDOL 1/2 AMPOULE AS PER PSYCHIATRY ADVICE.CT BRAIN WAS DONE TO RULE OUT HAEMORRHAGE >--------------&&-&& INFARCT WHICH TURNED OUT TO BE NORMAL .PATIENT DEVELOPED-------- TETANY SERUM Ca - 7.1CALCIUM GLUCONATE INFUSION WAS STARTED 6 AMPOULES IN 500ml NSABG : PH -7.40 PCO2 - 49. PO2 -148. HCO3-30.4
On 11/1/23:PATIENT WAS ORIENTED TO TIME ,PLACE,PERSON IN THE MORNING Na -138 K- 3.2. Cl- 97 Ca- 7.2CALCIUM GLUCONATE INFUSION IS CONTINUED .ABG : PH -7.47 PCO2 - 41.5 PO2 -88.6 HCO3-30.4
On 12/1/23:PATIENT WAS ORIENTED TO TIME ,PLACE,PERSON Na - 136 K-3.2. Cl- 94 Ca- 9.2 CALCIUM GLUCONATE INFUSION IS STOPPED ABG : PH -7.47 PCO2 - 38.9 PO2 -79.5 HCO3- 28.8PATIENT WAS ADVISED CT ABDOMEN TO RULE OUT ABDOMINAL TB BUT PATIENT ATTENDERS ARE NOT WILLING.
On 13/1/23:PATIENT IS CONSCIOUS, ORIENTED TO TIME,PLACE, PERSON Na - 139 , K- 3.4 Cl- 96 , Ca-8.5PATIENT IMPROVED SYMPTOMATICALLY AND IS DISCHARGED IN A STABLE CONDITION.
PULMONOLOGY CONSULTATION WAS TAKEN I/V/O ENDOBRONCHIAL TB , ADVISED SPU
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