70 year old male with altered behaviour ?HYPONATREMIA

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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)

29/11/2021


S-  having generalised weakness,c/o dry cough, conscious improved


O- conscious,coherent, cooperative, obeying verbal commands, Oriented to person ,place.
cough+ dry intermittently


PR-80bpmin
BP-120/80mmhg
CVS:S1,S2+
R.S:BAE+nvbs
p/a:soft,nt
cns:gcs:e4v5m6


serum sodium:
27/11-129
28/11-130
29/11-132

A-altered sensorium( resolved)secondary to hyponatremia (euvolemic)SIADH,?Chronic bronchitis (pt chronic smoker)



P- allowing fluids up to 1.5L/day
tab levipil 500mg/po /od--
serum sodium every 6 hours)