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CASE:
A 70 year old male came with chief complaints of :
1) Altered behaviour since afternoon.
2) Involuntary movements of the both upper limbs and lower limbs since 4pm along with loss of speech and involuntary movements of the mouth.
HOPI:
Patient was a security guard by occupation in Hyderabad 20 years back and there sons brought him to their village 20 years back and was doing nothing since then. He was normal till 1 month back and started developing decreased urine output, which was gradually progressive ,with poor stream of urine. No h/o of pedal edema, abdominal distension, SOB
He was taken to local hospital and was diagnosed with Renal failure ( creat 1.5 , with size of kidney 6cm with, Grade 1 prostatomegaly). He used the medication from the doctor only for one day and it did not gave him relief.
He used to take medication from RMP which used to increased his urine output for 4-5 days and gradually it decreases again , so when ever there is decreased urine output the patient attenders used to give a tablet and it increases his urine output and on 23rd November in the morning pt had complains of decreased urine output and his son gave one tablet and his urine output didn't increase, and he took one more tablet from his daughter in law and afternoon at 2pm when there was no one in the home , the neighbours watched him that he is using knife to cut on his abdomen to increase his urine output, being scared with his behaviour, the neighbours informed the attenders and attenders they returned home at 4pm in the evening and found that patient was having involuntary movements along with loss of consciousness and loss of speech.Then they brought to KIMS for further evaluation.
Past history:
He is a chronic smoker( since alduthood)
- 2 to 3 / day
He takes alcohol occassionally
Vitals:
Bp- 170/90 mmhg
PR-73 bpm
Spo2- 98% at room air
Rr- 20 cpm
Temp- Afebrile
GCS- E2V1M4
Involuntary movements of B/ L upper limbs
Tone increased in all four limbs
BGT: B +ve
RFT
s.Osm= 2x122+ 15.2/2.8 +199/18=260.48
urea = 23---48 (repeat)
Creat 2.1--1.5(repeat)
uric acid 4.6
Calcium=9.6
Po4---3.2
Na+---122
Cl-...82
K+...4.0
Hb = 9.2
TLC = 12,600
N°-90
L - 04
PCV --23.2
MCV-82.0
MCH = 32.5
RBC = 2.83
plabelets -1.94
NCNC
ABG
pH = 7.464
PCo₂ = 28.9
PO₂ = 77.0
HCO3 = 22.3
(P.stc)
HCO3 (pc) = 20.4
LFT
TB - 1.83
DB=0.62
AST - 36
ALT=24
ALP -191
TP=5.6
Alb-4.0
Serology
HIV- negative
HbsAg- Negatie
HCV- negative
Urinary electrolytes:
Na+ :251
K+ :20.4
Cl- :383
Retic count:0.6%
Repeat serum electrolytes
Na+ :114
K+ : 4.1
Cl- : 67
Diagnosis:-
Altered sensorium secondary to ?hyponatremia ( True hyponatremia)
? Hypervolemia hyponatremia
Treatment:
1) Inj. 3% Nacl@ 8ml/hr
2)Fluid Restriction <1lit / Day
3) Inj. Levpil 500mg/iv/bd
4)T.Pan 40mg /RT/od
5)RT feeds - Milk+
protein powder- @100ml 6th hourly
free water- 100ml/hour - 8th hrly
(Total <1L/day )
6)BP / PR/ spo2 charting 4th hrly
7)GRBS chaiting 8th hrly
8)Strict I/0 charting
Date-25/11/2021
S- involuntary movements of the mouth + but decreased, intermittent verbal response with sounds when called as described by attenders
O- conscious, delirious, not oriented to time,place,person
afebrile
PR-96/min
BP-130/70mmhg
CVS:S1,S2+
R.S:BAE+nvbs
p/a:soft,nt
cns:gcs:E4,V2,M4
reflexes: b t s k a-2+
plantars:b/l flexor
gag+
pupils:constricted not reacting to light
serum sodium:
23th admission-122mg/dl( 3% nacl was started)
24th -10 am-124mg/dl(3%nacl was continued)
4pm-114mg/dl(3@%nacl was stopped and fluids were restricted)
10pm-116mg/dl-tab tolvaptan 7.5 mg/po /given.
A-altered sensorium secondary to ?acute on chronic hyponatremia (euvolemic)
(?siadh. ? chronic diuretic use)
gtcs (resolved ) due to hyponatremia
chronic kidney disease
urethral stricture relieved.
P-
free water restriction via RT
inj levipil 500mg/po/bd
tab tolvaptan 7.5 mg/po/od
serum sodium every 6 hours
ckd-hyponatremia mostly due to hypervolemia,
diuretic use- due to hypovolemia
siadh- euvolemia
no hypotension, and signs of volume overload in our patient,
if siadh-what is the cause.?
should we restrat 3%nacl?
DATE: 26/11/2021
S- involuntary movements of the mouth completely decreased ,
patient is better,able to understand and replying when spoken to.
O- drowsy but arousable, obeying verbal commands,coherent, Oriented to person only
PR-82/min
BP-120/70mmhg
CVS:S1,S2+
R.S:BAE+nvbs
p/a:soft,nt
cns:
gcs: e4v3m6
reflexes: b t s k a-2+
plantars:b/l flexor
gag+
pupils:decreased size reacting to light
speech: slurred,
i/o:900/1600ml
serum sodium:
23th admission-122mg/dl( 3% nacl was started)
24th -10 am-124mg/dl(3%nacl was continued)
4pm-114mg/dl(3@%nacl was stopped and fluids were restricted)
10pm-116mg/dl-tab tolvaptan 7.5 mg/po /given.
25/11- 8am-114mg/dl- fluid restriction and 3%nacl
4pm-130mg/dl - continuing with fluid restriction
A-altered sensorium secondary to ?acute on chronic hyponatremia (euvolemic)
most probable acute : siadh due to? urinary attention,
(similar case report mentioned below)
diagnosis based on therapeutic response to fluid restriction and 3%nacl.
chronic:due to diuretics.
gtcs (resolved ) due to hyponatremia
chronic kidney disease
urethral stricture relieved.
P- free water restriction via RT
tab levipil 500mg/po/bd---taper to od from tomorrow.
serum sodium every 6 hours)
7am report to be collected
Case report 70/m
Our patient had chronic retention of urine due to urethral stricture. It has been postulated that chronic urinary retention and subsequent bladder distension can stimulate ADH release from the posterior pituitary, producing a clinical picture similar to SIADH [6, 7]. Although urinary retention may improve marginally with medications, surgical management can give a much better relief.
DATE: 27/11/2021
S- involuntary movements of the mouth completely decreased ,
patient is better,able to understand and replying when spoken to.
O- drowsy but arousable, obeying verbal commands,coherent, Oriented to person ,place.
cough+ dry intermittently
PR-97/min
BP-120/70mmhg
CVS:S1,S2+
R.S:BAE+nvbs
p/a:soft,nt
cns:gcs:e4v5m6
reflexes: b t s k a-2+
plantars:b/l flexor
gag+
pupils:decreased size reacting to light
speech: slurred,
i/o:850/1800 ml
serum sodium:
23th admission-122mg/dl( 3% nacl was started)
24th -10 am-124mg/dl(3%nacl was continued)
4pm-114mg/dl(3@%nacl was stopped and fluids were restricted)
10pm-116mg/dl-tab tolvaptan 7.5 mg/po /given.
25/11-8am-114mg/dl- fluid restriction and 3%nacl
4pm-130mg/dl - continuing with fluid restriction
26/11-8am 128mg/dl-tolvaptan 15mg od
4pm-130
27/11 8am to be collectd
A-altered sensorium secondary to ?acute on chronic hyponatremia (euvolemic)
most probable acute :siadh due to? urinary attention,
(similar case report mentioned below)
diagnosis based on therapeutic response to fluid restriction and 3%nacl.
chronic:due to diuretics.
gtcs (resolved ) due to hyponatremia
chronic kidney disease
urethral stricture relieved.
pre renal aki( secondary to fluid restriction)
P- free water restriction via RT
t.tolvaptan 15 mg /po/od
tab levipil 500mg/po /od--
serum sodium every 6 hours)
to reduce negative balance
case report.
Our patient had chronic retention of urine due to urethral stricture. It has been postulated that chronic urinary retention and subsequent bladder distension can stimulate ADH release from the posterior pituitary, producing a clinical picture similar to SIADH [6, 7]. Although urinary retention may improve marginally with medications, surgical management can give a much better relief.
ICU-bed 2-70/M 6https://muskaanmenghwani.blogspot.com/2021/11/this-is-online-e-log-book-to-discuss.html
S- involuntary movements absent ,
patient is better,able to understand and replying when spoken to.
O- conscious,coherent, cooperative, obeying verbal commands, Oriented to person ,place.
cough+ dry intermittently
PR-87bpmin
BP-120/80mmhg
CVS:S1,S2+
R.S:BAE+nvbs
p/a:soft,nt
cns:gcs:e4v5m6
reflexes: b t s k a-2+
plantars:b/l flexor
serum sodium:
27/11-129
28/11-130
A-altered sensorium secondary to ?acute on chronic hyponatremia (euvolemic)
most probable acute :siadh due to? urinary attention,
(similar case report mentioned below)
diagnosis based on therapeutic response to fluid restriction and 3%nacl.
chronic:due to diuretics.
gtcs (resolved ) due to hyponatremia
chronic kidney disease
urethral stricture relieved.
pre renal aki( secondary to fluid restriction)
P- allowing fluids up to 1.5L/day
tab levipil 500mg/po /od
(serum sodium every 6 hours)
..
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