urgent case discussion

65 yrs old female brought to hospital unresponsive state.previous history of cataract surgery one month back followed by PT developed accelerated hypertension and on telma H.after fewdays Patient developed altered conscious level.and also 2 episodes of vomiting. History suggest chronic alcoholic On examination vitals stable No fever,no sob,urine output normal Electrolytes Sodium 112meq- corrected 8 meq/d. MRI brain-chronic infact with cerebral atrophy(done after sodium correction) CBP- INITIALLY normal gradually WBC raising and HB FALL to 10gm to 6.9 gm. PLATLETS 1.8lakhs LFT,PT,INR,RFT, THYROID PROFILE, ELECTROLYTES (after correction)-NORMAL FEVER profile - normal(malaria ruled out) LP done-few lymphocytes and ADA normal(sugar 87mg/dl and protein 135mg/dl ).. Cxray normal. Planning for CECT ABDOMEN. but patient initially responded after 2 days she went back unresponsive state with locked in state... Im treating as encephalitis with merotec,linazolide and acyclovir,dexa injection.. Now WBC COUNT-. 8000 HB-6.9 platlets-1.8lakhs Please share your opinion

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Keep possibility of TBM Even ADA is normal Also rule out metabolic encephalopathy. Is there anything to suspect hepatic encephalopathy as history of chronic alcohol. Was pt on any drug which can cause hyponatremia?? If not must take it as CNS insult most probably due to some infection followed by hyponatremia. You can start att empirically till you get any definite etiology

LFT,PT,INR normal sir
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Chronic infarct with cerebral atrophy with ? Metabolic encephalopathy ? PTM S. Sodium were chronically less and needs to be corrected slowly otherwise can cause osmotic demyelination syndrome (ODS), a form of brain damage. Symptoms may not manifest for several days after a sodium overcorrection, and can include impaired speech or swallowing, limb weakness, seizures, confusion or depressed or loss of consciousness or in the most severe cases of pontine myolysis, locked-in syndrome. The damage and dysfunction can be permanent. The diagnosis of ODS is made by MRI, but brain changes may not be fully visible on imaging for weeks after the insult. Rx Tab CITICOLINE 500mg bd for 1 month Tab FERONIA XT OD for 1 month Tab ZINCOVIT OD for 1 month Tab TOLVAPTAN 15 mg for 1 week if Hyponatremia persist even after correction Continue anti hypertensive and other drugs Continuous monitoring to be done

Also Adv: CB NAAT of CSF
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Why can't it be a case of hypertensive encephalopathy?

Sir Increase protein and some what normal sugar in CSF can be viral encephalitis?
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Agree with Dr amar deep singh

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