case 13.64Male with pain lowerlimb and altered sensorium

Diagnosis

1. ACUTE ON CHRONIC HYPONATREMIA DUE TO IV FLUIDS WITH SEIZURES (SIADH) --

RECOVERED

2. ASPIRATION PNEUMONIA WITH SEPSIS --RECOVERED

3. CLOSED DISPLACED LEFT MEDIAL CUNEFORM + LATERAL DISPLACEMENT OF FRACTURE

BASE OF 2ND, 3RD, 4TH METATARSAL BONES

4. HYPERTHYROID STATUS (NEWLY DIAGNOSED) ?CAUSE

5. K/C/O TYPE II DM SINCE 10YRS --WELL CONTROLLED

6. K/C/O HYPERTENSION SINCE 1YR -- CONTROLLED ON ONE ANTIHYPERTENSIVE

Case History and Clinical Findings

C/O PAIN AND SWELLING OF LEFT LOWER LIMB SINCE 15DAYS WITH DIFFICULTY IN

WALKING.

HOPI :

PATIENT WAS APPARENTLY ASYMPTOMATIC 15DAYS AGO THEN HE DEVELOPED H/O

SPRAIN WHILE WALKING AND DEVELOPED SWELLING AND PAIN OF LEFT ANKLE

ASSOCIATED WITH DIFFICULTY IN WALKING.

HE IS K/C/O DM II AND HYPERTENSION AND WENT FOR FOLLOW UP IN NEAR BY HOSPITAL

AND FOUND TO HAVE UNCONTROLLED SUGARS(GRBS - 400MG/DL) AND TOOK TREATMENT

THERE.

PAST HISTORY :

K/C/O DM II SINCE 10YEARS AND ON TAB. ISTAMET 50/500MG, ON INJ. BIPHASIC ISOPHANE

INSULIN 20U S.C /OD

K/C/O HTN SINCE 1YR AND ON TAB. TELMA 40MG

NOT K/C/O TB, ASTHMA , EPILEPSY, CVA, CAD

NO H/O BLOOD TRANSFUSIONS

NO H/O SURGERIES.

PERSONAL HISTORY :

APPETITE NORMAL

BOWEL AND BLADDER MOVEMENTS REGULAR

NO KNOWN ALLERGIES

NO ADDICTIONS

FAMILY HISTORY : NOT SIGNIFICANT.

GENERAL EXAMINATION :

PATIENT IS C/C/C

HEIGHT : 160CM

WEIGHT : 52KG

BMI : 20.8 KG/M2

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, EDEMA

BP: 150/100 MMHG

PR: 96 BPM

RR: 26 CPM

SPO2: 98%

GRBS- 68 mg/dL

SYSTEMIC EXAMINATION

CVS- SI, S2 HEARD, NO THRILLS, NO MURMURS

RS- BAE +

ABDOMEN- SOFT, NON TENDER

CNS-

CRANIAL NERVES, MOTOR SYSTEM, SENSORY SYSTEM : INTACT AND NORMAL

GCS : E4V5M6

REFLEXES RT LT

B 2+ 2+

T 2+ 2+

S 1+ 1+

K 2+ 2+

A 1+ 1+

ORTHO REFERRAL WAS DONE ON 5/1/25 I/V/O LEFT FOOT PAIN SINCE 15DAYS AND WAS

DIAGNOSED AS LEFT CLOSED DISPLACED MEDIAL CUNEFORM WITH LATERAL 2ND, 3RD,

4TH METATARSAL FRACTURES. AND WAS ADVICED WITH

1. CREEPE BANDAGE APPLICATION

2. TAB. CHYMEROL FORTE PO/TID

3. TAB. NEUROKIND LC PO/OD

4. CONTINUE SAME TREATMENT

OPTHALMOLOGY REFERRAL WAS DONE ON 7/1/25 I/V/O FUNDOSCOPIC EXAMINATION FOR

PAPILLEDEMA.

IMPRESSION : NORMAL FUNDUS STUDY.

COURSE IN THE HOSPITAL :

PT WAS ADMITTED I/V/O ABOVE MENTIONED COMPLAINTS , WAS EVALUATED AND WAS

DIAGNOSED AS GTCS SECONDARY TO HYPOTINIC HYPONATREMIA (SIADH) WITH

ENCEPHALOPATHY (RESLOVED), SEPSIS SECONDARY TO ASPIRATION PNEUMONIA

(RESOLVING), CLOSED DISPLACED LEFT MEDIAL CUNEFORM + LATERAL DISPLACEMENT

OF FRACTURE BASE OF 2ND, 3RD, 4TH METACARPAL BONES., K/C/O TYPE II DM SINCE

10YEARS AND HYPERTENSION SINCE 1YEAR . PATIENT HAD ONE EPISODE OF SEIZURE

ACTIVITY ON THIRD DAY OF ADMISSION AND SODIUM LEVELS WERE 117 WAS STARTED ON

IV FLUIDS 0.9%NS , 3%NS INFUSION, ANTIEPILEPTICS, TOLVAPTAN . PATIENT DEVELOPED

CONTINUOUS FEVER SPIKES FOLLOWING SEIZURE ACTIVITY WITH RAISED WBC COUNTS

AND WAS SUSPECTING ASPIRATION PNEUMONIA AND WERE TREATED WITH IV

ANTIBIOTICS, ANTIPYRETICS .PATIENT WENT INTO SEPTIC SHOCK SECONDARY TO

ASPIRATION PNEUMONIA DEVELOPED HYPOTENSION DURING 4TH DAY OF ADMISSION

AND STARTED HIM ON NORADRENALINE INFUSION FOR 48HRS AND TAPPERED

ACCORDINGLY.PATIENT SENSORIUM IMPROVED AND SUPPORTIVE MANAGEMENT

CONTINUED . ORTHO REFERRAL WAS TAKEN I/V/O LEFT ANKLE SPRAIN AND SWELLING

AND DIAGNOSED WITH METACARPAL FRACTURES AND CRAPE BANDAGE WAS

ADVISED.PATIENT IMPROVED SYMPOTAMATICALLY BETTER AND PATIENT IS BEING

DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION.

Investigation

RFT 05-01-2025 09:20:PMUREA 30 mg/dl 50-17 mg/dlCREATININE 1.0 mg/dl 1.3-0.8 mg/dlURIC

ACID 2.1 mmol/L 7.2-3.5 mmol/LCALCIUM 9.5 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.1 mg/dl 4.5-

2.5 mg/dlSODIUM 125 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

88 mmol/L 98-107 mmol/L

ABG 05-01-2025 09:20:PMPH 7.44PCO2 20.2PO2 115HCO3 13.6St.HCO3 16.7BEB -9.4BEecf -

9.7TCO2 29.5O2 Sat 98.3O2 Count 8.9

LIVER FUNCTION TEST (LFT) 05-01-2025 09:20:PMTotal Bilurubin 0.75 mg/dl 1-0 mg/dlDirect

Bilurubin 0.21 mg/dl 0.2-0.0 mg/dlSGOT(AST) 39 IU/L 35-0 IU/LSGPT(ALT) 18 IU/L 45-0

IU/LALKALINE PHOSPHATASE 169 IU/L 119-56 IU/LTOTAL PROTEINS 7.7 gm/dl 8.3-6.4

gm/dlALBUMIN 4.05 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.11

COMPLETE URINE EXAMINATION (CUE) 05-01-2025 09:20:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +++SUGAR ++BILE

SALTS NilBILE PIGMENTS NilPUS CELLS 4-5EPITHELIAL CELLS 2-4RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

POST LUNCH BLOOD SUGAR 05-01-2025 09:22:PM 258 mg/dl 140-0 mg/dl

Anti HCV Antibodies - RAPID 05-01-2025 11:14:PM Non ReactiveHBsAg-RAPID 05-01-2025

11:14:PM Negative

SERUM ELECTROLYTES (Na, K, C l) 06-01-2025 07:50:AMSODIUM 120 mmol/L 145-136

mmol/LPOTASSIUM 4.7 mmol/L 5.1-3.5 mmol/LCHLORIDE 86 mmol/L 98-107 mmol/LSERUM

ELECTROLYTES (Na, K, C l) 06-01-2025 10:58:PMSODIUM 124 mmol/L 145-136

mmol/LPOTASSIUM 4.1 mmol/L 5.1-3.5 mmol/LCHLORIDE 87 mmol/L 98-107 mmol/L

ABG 06-01-2025 10:58:PMPH 7.43PCO2 34.7PO2 30.2HCO3 23.1St.HCO3 23.6BEB -0.3BEecf -

0.6TCO2 47.9O2 Sat 64.6O2 Count 9.1

SERUM ELECTROLYTES (Na, K, C l) 07-01-2025 12:13:AMSODIUM 117 mmol/L 145-136

mmol/LPOTASSIUM 4.3 mmol/L 5.1-3.5 mmol/LCHLORIDE 80 mmol/L 98-107 mmol/L

SERUM ELECTROLYTES (Na, K, C l) 07-01-2025 02:01:PMSODIUM 128 mmol/L 145-136

mmol/LPOTASSIUM 4.0 mmol/L 5.1-3.5 mmol/LCHLORIDE 80 mmol/L 98-107 mmol/L

SERUM ELECTROLYTES (Na, K, C l) 07-01-2025 06:14:PMSODIUM 130 mmol/L 145-136

mmol/LPOTASSIUM 3.8 mmol/L 5.1-3.5 mmol/LCHLORIDE 99 mmol/L 98-107 mmol/L

SERUM ELECTROLYTES (Na, K, C l) 07-01-2025 10:49:PMSODIUM 130 mmol/L 145-136

mmol/LPOTASSIUM 3.7 mmol/L 5.1-3.5 mmol/LCHLORIDE 96 mmol/L 98-107 mmol/L

SERUM ELECTROLYTES (Na, K, C l) 08-01-2025 04:43:PMSODIUM 135 mmol/L 145-136

mmol/LPOTASSIUM 3.9 mmol/L 5.1-3.5 mmol/LCHLORIDE 96 mmol/L 98-107 mmol/L

ABG 08-01-2025 04:43:PMPH 7.402PCO2 32.9PO2 25.3HCO3 20.0St.HCO3 20.6BEB -3.6BEecf -

3.9TCO2 42.1O2 Sat 48.8O2 Count 6.8

ABG 08-01-2025 09:48:PMPH 7.386PCO2 34.8PO2 32.0HCO3 20.4St.HCO3 21.0BEB -3.6BEecf -

3.7TCO2 43.9O2 Sat 62.2O2 Count 7.2

RFT 08-01-2025 11:26:PMUREA 51 mg/dl 50-17 mg/dlCREATININE 1.5 mg/dl 1.3-0.8 mg/dlURIC

ACID 2.7 mmol/L 7.2-3.5 mmol/LCALCIUM 9.7 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.4 mg/dl 4.5-

2.5 mg/dlSODIUM 133 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

96 mmol/L 98-107 mmol/L

ABG 08-01-2025 11:26:PMPH 7.38PCO2 30.7PO2 31.6HCO3 17.9St.HCO3 19.1BEB -5.9BEecf -

6.2TCO2 38.3O2 Sat 61.6O2 Count 7.5

RFT 09-01-2025 10:59:PMUREA 38 mg/dl 50-17 mg/dlCREATININE 1.2 mg/dl 1.3-0.8 mg/dlURIC

ACID 2.0 mmol/L 7.2-3.5 mmol/LCALCIUM 9.5 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.0 mg/dl 4.5-

2.5 mg/dlSODIUM 139 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

99 mmol/L 98-107 mmol/L

ABG 09-01-2025 10:59:PMPH 7.36PCO2 35.1PO2 33.1HCO3 19.6St.HCO3 20.1BEB -4.7BEecf -

4.8TCO2 41.9O2 Sat 64.3O2 Count 8.0

2D ECHO WAS DONE ON 07/01/2025

TACHY CARDIA DURING STUDY

- NO RWMA

- MILD CONCENTRIC LVH +(1.20CM)

- MILD TR+ WITH PAH

- TRIVIAL AR+/MR+; NO AS/MS

- SCLEROTIC AV; MV-AMLTHICKENED

- EF = 59% GOOD LV/RV SYSTOLIC FUNCTION

- GRADE I DIASTOLIC DYSFUNCTIONAL+

- IVC SIZE(0.8CM) COLLAPSING

- MINIMAL PE; NO LV CLOT

IVS - 1.18CM

ESD - 3.72CM

EDD - 5.45CM

DPW - 1.18CM

LFT (15/1/25):

TB-0.47

DB-0.17

SGOT-19

SGPT-18

ALP-17

T PROTIENS-6.6

ALBUMIN-3.2

A/G RATIO-0.95

SERUM CREATININE-1.0

SERUM ELECTROLYTES(15/1/25)

Na-136

K-4.3

CL-102

Ca-1.21

SPOT UPCR:

URINE PROTEIN-7.0

URINE CREAT-35.7

RATIO-0.19

CUE:

COLOUR-PALE YELLOW

APPEARANCE-CLEAR

ALBUMIN-NIL

SUGARS-+

BILE SALTS-NIL

BILE PIGMENTS-NIL

PUS CELLS-2-4

EPITHELIAL CELLS-2-3

RBC-NIL

CRYSTALS-NIL

HEMOGRAM:

HB-9.3

TLC-8,900

N/L/E/M/B-65/22/04/09/00

PCV-26.5

MCV-83.9

MCH-29.4

PLATELETS-4.19

RBC-3.15

HEMOGRAM ON 15/1/25

HB - 9.3 , TLC - 8900, PCV - 26.5 , RBC - 3.15 ,PLT - 4.19

CUE 15/1/25

ALB -NIL,SUG-+,PUSCELLS AND EPICELLS -2TO3 ,

RFT ON 15/1/25

CREAT -1.0 ,SODIUM - 136,POTASSIUM - 4.3 ,CHLORIDE - 102

LFT ON 15/1/25

TB-0.47 ,DB - 0.17, SGOT - 19, SGPT-18, ALP-117,TP-6.6,ALB-3.2

THYROID PROFILE:

FREE T4-1.8

TOTAL T3-76

TSH-0.521

CORTISOL-11.4

HGH-2.13

TESTOSTERONE-104

FREE T3-2.42

TOTAL T3-76

FREE T4-1.8

TOTAL T4-10.5

TSH-0.45

Treatment Given(Enter only Generic Name)

1. RT FEEDS - 100ML MILK 4TH HRLY

10MML WATER 2ND HRLY

2. IV FLUIDS 0.9% NS @ 50ML/HR

3. IV FLUIDS 3%NS @15ML/HR FOR 24HRS

4. INJ. LINEZOLID 600MG IV/BD FOR 7DAYS

5. INJ. CLINDAMYCIN 600MG IV/TID FOR 7DAYS

6. INJ PIPTAZ 4.5GM IV/TID FOR 7DAYS

7. INJ. LEVIPIL 500MG IV/BD FOR 7DAYS

8. INJ. NEOMOL 1G IV/SOS IF TEMP >101F

9. INJ. LANTUS SC/OD/BED TIME X----X-----12U

10. TAB. TOLVAPTAN 15MG PO/OD FOR 5DAYS

11. TAB. CHYMEROL FORTE PO/TID

12. TAB. NEUROKIND PO/OD

13. TAB ISTAMET 50/500MG PO/BD

14. TAB TELMA 40MG PO/OD.

15. INJ. CLEXANE 60U SC/OD.

16. INJ. NORADRENALINE 2AMP IN 40ML NS @ 1ML/HR INCREASE OR DECREASE

ACCORDING TO MAINTAIN MAP >65MMHG

17. GRBS 4TH HRLY BEFORE FEEDS.

18. CREEPE BANDAGE APPLICATION OF LEFT ANKLE.

19. POSITION CHANGE 2ND HRLY.

20. CHEST PHYSIOTHERAPY.

21. INPUT AND OUTPUT CHARTING.

Advice at Discharge

1. TAB LEVOFLOXACIN 500MG PO/BD FOR 5DAYS

2. TAB ISTAMET 50/500MG PO/BD X TO CONTINUE

3. TAB NEUROKIND -LC PO/OD X 1 MONTH

4. TAB CHYMEROL FORTE PO/TID X 1 MONTH

5. TAB TELMA 40MG PO/OD X TO CONTINUE

6. TAB PANTOP 40MG PO/OD 7AM X 1MONTH

7. INJ. LANTUS SC/OD/BED TIME X----X-----12U

8. CREPE BANDAGE APPLICATION OVER LEFT ANKLE.

9. HOME GLUCOSE MONITORING AT BEFORE BREAKFAST ,BEFORE LUNCH,BEFORE

DINNER AND BEDTIME.

Follow Up on feb 2025

Fbs 110 mg/dl

plbs 145 mg/dl

hba1c 5.9