73yr old male

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

Case Scenario
A 73 yr old male came to medical OPD with chief complaints of fall ( slipped) when he went for urination .

HISTORY OF PRESENT ILLNESS

Yesterday morning at around 5:00 Am pt went for urination at outside and fainted and fell on ground and no post fall Loss of consciousness, seizures, vomitings pt walked and slept. At around 8:00 Am pt couldn't walk and was taken to pvt hospital 
Investigations were done showing Hyponatremia, low serum osmolarity with high spot sodium Euvolumic state 
CT brain shows diffuse cerebral atrophy with small vessel ischemia  

2D Echo shows WNL

Na+ 206,K+ 3.0,Cl- 69

HISTORY OF PAST ILLNESS
15 yrs back stopped working due to joint pains, weakness
Pt was apparently asymptomatic 4-5 yrs back then ge went to local hospital with weakness and diagnosed with HYPERTENSION and started using medication( Met XL 25 mg) regularly.
2-3 yrs back due to polyuria went for local hospital and diagnosed with DM and started using OHA and
With complaints of Pain in Abdomen and diagnosed with Gall stones and started using medication and subsided 
Not a k/c/o of TB,Asthama, epilepsy, CAD.

TREATMENT HISTORY
Using Medication for DM ,
 HYPERTENSION (Met XL 25 mg/ PO/OD)
used Medication for Gallstones
No blood transfusions

PERSONAL HISTORY

Diet: veg
Apettite- lost 
Bowel : Irregular,hard stool, once in 3 days
Micturition: Abnormal , decreased
No known Allergies 
No Addictions

FAMILY HISTORY
No relavent family history

ON EXAMINATION
Pt is conscious, coherent,co operative and well oriented with time and place

GENERAL EXAMINATION
Pallor : no
Cyanosis: no
Clubbing: no
Icterus: no
Oedema: no
Dehydration: no

VITALS
Temperature : 98.6 f
Pulse rate : 82/min
Respiratory rate : 18/min
BP:110/70 mmHg
GRBS :105

SYSTEMIC EXAMINATION
CVS
Cardiac sounds: S1S2 present
Thrills:No
Murmur: no

RESPIRATORY SYSTEM
Dyspnoea :no
Wheeze :no
Trachea position: central
Breath sounds : vesicular

ABDOMEN
Shape of Abdomen : scaphoid
Tenderness : no
Palpable mass : no
Free fluid: no
Bruits : no
Bowel sounds : yes
Liver,spleen : Not palpable 

CNS
Conscious
Speech : normal
neck stiffness : no
Kernings sign : no
Provisional Diagnosis
HYPOOSMOLAR HYPONATREMIA

  INVESTIGATIONS
FEVER CHART
ECG
TREATMENT::
17/07/2022
1) normal diabetic diet
2)Inj 3% NaCl 15 ml / hr infusion
3)Inj.Zofer 4 mg IV 
4) Inj.HAI s/ c according to GRBS
5) vitals Charting
6) serum Electrolytes every 12 th hrly

18/07/2022
1)normal diabetic diet
2)Inj 3% NaCl 15 ml / hr infusion
3)Inj.Zofer 4 mg IV 
4) Inj.HAI s/ c according to GRBS
5) vitals Charting
6) serum Electrolytes every 12 th hrly
7) Lubrex eye drops ( 1 drop in each eye 6 times daily)
8) syrup Creamaffin 15 ml / PO

19/07/202
1) Normal diabetic diet
2) take salty food
3)Tab Zofer 4 mg /PO
4) Ambulation
5) vitals Charting
6) serum Electrolytes every 12 th hrly
7) Lubrex eye drops ( 1 drop in each eye 6 times daily)
8) syrup Creamaffin 30 ml

20/07/202
1)Normal diabetic diet
2) take salty food
3)Tab Zofer 4 mg /PO
4) Ambulation
5) vitals Charting
6) serum Electrolytes every 12 th hrly
7) Lubrex eye drops ( 1 drop in each eye 6 times daily)
8) syrup Creamaffin 15 ml

21/07/202
1 ) High Salt intake
2) Tab Zofer 4 mg/PO
3) Ambulation
4)Lubrex eye drops ( 1 drop in each eye 6 times daily)

22/07/2022
1) High Salt and normal diabetic diet
2) Tab Zofer 4 mg/PO
3) Zytee gel 
4) Lubrex eyedrops
5) Ambulation
6) syrup Potklor 
7) Tab B complex PO

23/07/2022
) High Salt and normal diabetic diet
2) Tab Zofer 4 mg/PO
3) Zytee gel 
4) Lubrex eyedrops
5) serum Electrolytes every 12th hrly
6) Ambulation
7) syrup Potklor 
8) Tab B complex PO

24/07/2022
1)High Salt and normal diabetic diet
2) Tab Zofer 4 mg/PO
3) Zytee gel 
4) Lubrex eyedrops
5) serum Electrolytes every 12th hrly
6) Ambulation
7) Tab B complex PO

25/07/2022
1) High salt diet
2) T .zofer 4mg
3) T.Zytee gel
4) T.B complex
5) Lubrex eyedrops
6) Ambulation
7) sr.electrolyte for every 12 hrs
8) syrup Potklor

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