A 52 year old male with giddiness,Vomitings,Loose stools 2 days back Involuntary movements of bilateral upper limbs since yesterday morning

March 28, 2023

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A 52 year old male came with the chief complaints of giddiness since 3 days

Vomitings 2 days back

Loose stools 2 days back

Involuntary movements of bilateral upper limbs since yesterday morning

History of presenting illness

Patient was apparently asymptomatic 3 days ago then he developed giddiness sudden onset more on standing and later progressed to giddiness on supine position

Vomitings 2 days ago 3 to 5 episodes/day content as food particles non bilious non projectile and non blood stained

Loose stools 2 days ago about 3 to 5 episodes per day normal consistency

Involuntary movements of Hands and fingers since morning

No history of loss of consciousness, up rolling of eyeballs, involuntary micturition or defecation and headache

Detailed history

52 year old male , who is father of 2 children ( one daughter and who does marketing by occupation was apparently asymptomatic 22 years back .

At 28 years of age ,he used to work as a private school teacher and got married and went to the abroad ( Dubai) and started working as store manager in Dubai and used to come to India once in a year.

6 years back, as patient want to stay in India and came back from abroad and started marketing ( used to sell biscuits ) and from then he used to have clashes with his wife.

1 and 1/2 year back, patient seperated from his wife and children and started leaving alone in a single room , which is a very hot and doesn't have proper ventilation.

4 days back patient wife and her brother called him and asked him regarding his properties and from then onwards , he was feeling stressed and on the same day he was on fasting ( rojha ) and on the next day onwards patient had vomtings 2episodes along with loose stools 5 episodes and next day onwards patient started having giddiness and slightly drowsy and brought here for further evaluation.

No addictions.

Past history

K/c/o HTN since 5 to 6 years and on medication telmisartan 40 mg

General physical examination

Patient is concious coherent and cooperative

Vitals on admission

Bp 130/90

PR 96

RR 20

Temp 96.8F

Spo2 97 on room air

Grbs 117 mg/dl

No pallor icterus cyanosis clubbing lymphadenopathy and edema

Systemic examination

CARDIO VASCULAR SYSTEM

S1S2 +

No murmurs

RESPIRATORY SYSTEM:

BAE present

Position of Trachea – Central

Normal vesicular breath sounds present

ABDOMEN

Shape of abdomen – scaphoid

Bowel sounds are present

CNS

Higher mental functions intact

Pupils bilateral NSRL

Sensory examination - couldn't be assessed

Motor-

Tone-

Rt. Lt.

UL N. N

LL. N. N

Power

Rt. Lt

UL. 5/5. 5/5

LL. 5/5. 5/5

Reflexes-

B. T. S. K. A. Supinator

Rt. - - - - - Extension

Lt. - - - - - Extension

Provisional diagnosis

Giddiness under evaluation

Hyponatremia under evaluation

True hyponatremia

Hypovolemic hyponatremia (serum osmolality 238)

(Hypovolemic hyponatremia)

Investigations

HB 13.6

Pcv 35.1

TLC 19000

RBC 4.67

Plt 2.87

Esr 5

Grbs 112

Blood urea 12

S creatinine 0.7

Serum sodium 121 to 119

Serum potassium 3.7 to 3.8

Serum chloride 86 to 74

Aptt 34 sec

TB 2.45

DB 0.59

Sgpt 38

Sgot 83

Alkaline phosphatase 131

Total proteins 6.9

Albumin 4.2

A/G ratio 1.52

Serum calcium 9.5

Magnesium 2.0

Serology negative

On 28/3/23

on 28/3/23

on 29/3/23

Treatment

Iv fluids 0.9%NS at 75 ml/hr

Inj optineuron 1 amp in 100ml NS/IV/OD

Inj pan 40mgg IV/OD

Inj metrogyl 500mg IV/TID

Tab oflox oz (200/500mg) PO/BD

Inj zofer 4 mg IV/BD

29/3/23

SOAP notes

C/o SOB and irritable behavior

Stools passed yesterday night

Involuntary movements decreased compared to previous day BP

Patient is irritable

Oriented to time place and person

Vitals

BP 150/110 mmhg

PR 82 bpm

Temp 96.4 F

RR 24 per min

Spo2 92 on room air

Cvs S1 S2 heard no murmurs

RS bilateral air entry present

Normal vesicular breath sounds diffuse

Wheeze present

CNS

Gcs E4V5M6