A 40-year old obese female was admitted with altered sensorium, a history of vomiting and documented hyponatremia followed by fluctu-ating encephalopathy and a deep coma state. She was initially managed at a peripheral health center where her serum sodium was 98 mEq/L. She was treated for severe hyponatremia (duration of hyponatremia and rate of correction not known) with a slight improve-ment noticed by her family members initially. The pa-tient was managed inititally at a primary health center by a primary care physician with slight improvement but soon developed fluctuating encephalopathy and was shifted to our medical center. On admission, the patient was still in a stuperous state with spontaneous guttural vocalization only and no active movement of her limbs. On examination, the patient had asymmetrical extra-pyramidal signs-more on the right side compared to the left. The patient had normal pupillary reflexes and
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