70 year old male patient with altered behaviour and involuktary movemnts of limbs

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A 70 year old male came with chief complaints of : 

With Altered behaviour since afternoon.

And

 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 security guard  20 years back and now since 20 years he is not doing any work.

He was normal till 1 month back and started developing decreased urine output, which was gradually progressive.

No h/o of pedal edema, abdominal distension and SOB was seen 

He was taken to local hospital  and was diagnosed with Renal failure with creatine 1.5 

He started using medication from an RMP doctor to increase his urine output. 

But as he uses the medication(once he takes a tablet) his urine output comes to normal for next 3 to 4 days but later it again stars decreasing. 

So when ever patient had decreased output again, he was given that medication by the patient attenders

On 23rd nov ,when he was the tablet there was no increase in urine output as before, so he was given one more tablet by the attenders. 

That 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 as 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

Past history:

Personal history:

Mixed diet

He is a chronic smoker( since 2nd decade of his life) 

- 2 to 3  per day

Alcohol consumption 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