Welcome

to
Grand Round
Presentation
Dr. Aziza M.A. Rahman
FCPS Course ( Orchid Unit)
Internal Medicine
Particulars of the Patient

 Mrs. Johora Begum

 55 years
 House-wife
 Normotensive, Non-diabetic
 House-wife
 Address: Pabna
 Date of admission: 9th May, 2022
Presenting Complaints:

1. Intractable Vomiting for 1 month

2. Generalized weakness for 1 month
 Background History

4th April, 2022:

 History of RTA
 Developed sudden loss of consciousness
 Brought to a local hospital in Pabna
 Hospitalized for 2 days
 During hospitalization, she regained consciousness after
about 2 hours but developed sudden onset of intractable
vomiting.
 Background History

• CT Scan of Head: 5th April, 2022

Comment:

Bilateral Cerebral (frontal region)

acute contusion haemorrhage with
Mild peri-lesional oedema
 CT
Scan
Of
Head
 Background History
07.04.22
 Referred to a Neurosurgery Department of a hospital in
Khulna .
 Evaluation revealed Electrolyte Imbalance in the form of
Severe Hyponatremia:
Na+ 119 mmol\L
K+ 3.80 mmol\L
Cl- 84.4 mmol\L
 Background History
 Patient was conservatively treated with the following drugs:
-300 ml of 3% NaCl daily
9 days
-Inj. Dexamethasone (5mg) TDS

-Inf. Normal saline 1 L Daily

24 days
- Inj. Dexamethasone (5mg) BD

 Clinical condition showed no improvement.

Background History ( S. Electrolyte)
12.02.22 14.04.22 19.04.22 26.04.22 30.04.22 07.05.22
Na+ 114 123 103 121 114 115
mmol\L
K+ 4.1 mmol\ 4.4 4.2 4.0 4.6 3.8
L
Cl- 82 88 73 90 85 84
mmol/L

Inj. 3% NaCl ( 300 ml) Inj. Normal Saline ( 1000ml)

 Background History
 Since the patient’s condition still kept deteriorating

 Vomiting and generalized weakness persistent

 S. Na+ level kept fluctuating, despite of adequate NaCl

supplementation.

 Patient was referred to BSMMU for further evaluation.

 During Admission (09.05.22)
 Chief Complaints:
1. Intractable vomiting for 1 month
2. Generalized weakness for 1 month
3. Vertigo for 1 month

 On examination:
1. Anaemic
2. BP:120/70 mm Hg ( no postural drop)
3. Pulse: 84/min, regular
During Admission (Investigations)
17.05.22 20.05.22
Hb% 9.6 g/dl 10.9 g/ dl
ESR 10 mm in 1st hr 20 mm in 1st hr
WBC 8000/L 8,700/L
Platelet 2,05,000/L 2,99,000/L
MCV 69.9fl
MCH 23.8pg
MCHC 34.1g/dl
CRP 27.6 mg/L
During Admission (Investigations)
10.05.22 12.05.22 15.05.22 18.05.22 20.05.22

Na+ 106 111 121 121 119

K+ 5.3 4.0 3.8 3.8 2.9

Cl- 75 80 87 87 87

TCO2 18 18.9 20.4 20.4 23.3

During Admission (Investigations)
17.05.22 28.05.22
S. Creatinine 0.62 mg/dl
S. Urea 3.6 mmol/l 24.5mg/dl
Urine R/M/E Pus cells: 2-4/HPF
24 hrs Urine volume 900 ml/ day
24 hrs UTP 0.52gm/day
Plasma Osmolality 251 mOsmol/kg
(285- 295)
Urine Osmolality 169 mOsmol/kg 293 msOsm/Kg
(300-900) (Normal:300-900)

Urine Na+ 20 mmol/L 101 mmol/L

During Admission (Investigations)

TSH 0.31 micro/ml

FT4 20.38pmol/L
LH 2.01IU/L
FSH 39.19IU/L
S. Cortisol 59.77 nmol/L
ACTH 5 pg/ml
M
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B
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 MRI of Brain

 Gliotic areas in
frontal lobes

 Suggestive of
meningitis along
fronto-temporal
margin.
CXR P/A View

Reveals
Normal findings
 Provisional Diagnosis

 Frontal Contusion with

 Persistent hyponatremia due to:

1. SIADH
2. Cerebral Salt Wasting Syndrome
3. Adreno-cortical insufficiency
Ongoing Treatment

 Diet: Fluid restriction

 Inf. 3% NaCl for 3 days, then
 Inf. NS (1L)
 Inj. Dexamethasone i/v Once Daily
 Tab. Fludrocortisone (0.1 mg) 1 + 0 + 1
 Tab. NaCl 300 mg 3 + 3 + 3
 Inj. Ceftriaxone 2 gm
 8 days after admission…
 Patient suddenly developed transient loss of consciousness
for about 3- 4 times

 Features of hypovolemic shock:

• BP: 85/40 mmHg
• Pulse: 110/min, feeble
• Sp02: 98%

 Referred to ICU.
ICU Admission:

 Hypovolemic shock was corrected with IV Normal

saline (2.5L) daily
 Inj. Piperacillin + Tazobactam 4.5gm TDS for 7 days
 Inj. Moxifloxacin 400 mg daily for 7 days
 Inj. Dexamethasone 5 mg daily
 Tab. NaCl 300 mg 3 +3+3
MRI
of
Pituitary Gland
MRI Report:
Ongoing Treatment

 Diet: Fluid restriction

 Tab. Dexamethasone (5mg)
 Tab. Fludrocortisone (0.1 mg) 1 + 0 + 1
 Tab. NaCl 300 mg 3 + 3 + 3
 Tab. Omeprazole ( 20 mg)
Current Situation of the Patient

 The patient is now clinically improved.

 Vomiting subsided .
 Weakness improved.
 Recent Investigation:
30.05.22
Na+ 146 mmol/L
K+ 4.1 mmol/L
Cl- 100 mmol/L
T-CO2 26.6 mmol/L
Problem List