80/Y/M with slurring of speech and hypertonia

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A 80 year old male patient resident of Ramanapet and a reteired bank bank manager came with a chief complaints of 

• slurring of speech since 5 days 

• contractions  of 4 limbs since 5 days (hypertonia) 

• unable to identify people since 5 days 

• excessive sleepyness since 5 days

•  fever 3 days back which was insidious in onset and gradually progressive and subsided on taking medication .

History of presenting illness 

The patient was apparently asymptomatic 3 months back then he developed blackish discoloration of right 4th toe for which he was advice to go for amputation of right 4th toe and was operated 

20 days back the attender observed that the patient has 

•loss of appetite

• decreased intake of food and 

• unable to identify people 

• bilateral swelling of knee joint for which he was taken to near by hospital and managed conservatively .

No history of head ache , seizures , nausea , vomiting .

Past history

Patient was a known case of hypertension since >30 yrs and on medication 

Known case of diabetes since 5 - 6 yrs  and on medication

Patient is suffering from Rheumatoid arthritis since 15 yrs  and he is not on medication

Not a known case of TB , epilepsy , asthma.

Personal history 

Diet : now the patient was taking a smooth diet 

Appetite : decreased ( according to attender)

Sleep : adequate 

Addictions : chronic alcoholic ( 90ml )

Family history

He had a sister who died due to high sugar levels 

Another sister who is alive has hypertension and diabetes and she is on medication 

General examination 

Patient was conscious not oriented to time place and person 

Well built and nourished 

Pallor - present

No ictherus , cyanosis, clubbing , lymphadenopathy

Edema is present that is pitting type

Vitals : 

Systemic examination

CVS : inspection no scars or sinus no engorged veins 

 Auscultation S1 S2 heard no murmors 

Respiratory : on inspection shape of chest normal 

On palpation chest expansion was bilaterally symmetrical 

On auscultation normal vesicular breath Sounds heard no stridor

GIT : 

On inspection 

Abdomen was distanded 

3 round hyper pigmented lesions are seen ( may be scars )

Umbilicus everted 

Palpation : abdomen was soft non tender 

No organomegaly was found 

Auscultation : bowel sounds are heard 

CNS :

Pupils : bilateral pseudophakia

Tone : increased in both limbs on both sides  suggesting spasticity 

Power : 3/5  for both upper and lower limbs on both sides

Reflexes             Rt               Lt

Biceps.              +2                +2

Triceps.            +2                +2 

Ankle                 -                    -

Knee.                +2                +2

Plantar : elicited on both sides 

No menningial signs 

Investigations :

Diagnosis

True hyponatremia secondary to drug induced with past h/o DM and HTN with anemia under evaluation

Paln 

1. Head end elevation upto 30°
2. IVF - 3% NaCl @ 4ml/hr to be increased or decreased according to electrolytes
3. INJ PAN 40mg /IV/OD
4. INJ NEOMOL 100ml ( if temperature >101.1°f )
5.INJ.THIAMINE 1amp in 100ml NS/IV/BD
6. RT feeds 100ml milk and 100ml free water 2nd hrly
7.vitals monitoring