1801006008 CASE PRESENTATION
CHEIF COMPLAINTS
Unstable gait and tremors since last 10 days
HISTORY OF PRESENT ILLNESSES
patient was apparently asymptomatic 12 years ago then he started taking alcohol in the form of ARRACK for the first time with his friends and mentions that he enjoys drinking it , as it was available in his farm he started drinking every alternative day about 1-2 glasses a day
2 years later his mother passed away in a tragic accident and to alleviate that stress he started drinking heavily , over the next few months his consumption gradually increased to 3 glasses a day further to 6 glasses a day.This continued upto 5 years after he started drinking
Around 5 years later he shifted to WHISKY due to ARRACK being banned by the government.He drink around 2 units of whisky daily before going to work and upon returning in the evening he used to feel tired thus used to drink again.
In a few months time his drinking increased upto 12 units a day .
He also complains of sleep disturbances,decreased appetite and sweating if he does not consume alcohol .
Patient also complains of visual hallucinations, tremors and pins and needles sensations .
His family then enrolled him in a deaddiction programme
patient also started chewing tobacco since the last 9 years , around 1 packet every 2-3 days
no history of any psychiatric conditions
no history of any head injury
no history of any loss of consciousness
no history of any epilepsy or involuntary movements
No fever , vomiting or stiffness of neck
No weakening of limbs , no wasting or thinning of muscles
DAILY ROUTINE
patient wakes up at 5 in the morning and freshens up and does all his household chores then has a small glass of alcohol following which he goes to work as a an auto driver , he returns home at around 2 to have lunch and takes another 1-2 glasses of alcohol and goes back to work then he comes back home to have dinner at about 9 and sleeps thereafter
patients family members claim that he sneaks out at night to consume more alchol and gets into physical altercation with his family frequently when confronted
PAST HISTORY:
Not a known case of hypertension, diabetes mellitus , epilepsy, asthma ,tb , cad , cvd , thyroid
Patient had a history of fracture to the left arm following an accident resulted in him getting fixed with a DCP PLATE
PERSONAL HISTORY :
Appetite - normal
Diet - mixed , inadequacy in nutrition
Sleep - disturbed
Bowel and bladder movement- regular
Addictions : alcohol consumption since the age of 11 years
chewing of gutka since the age of 11 years -
Allergies : No allergies
GENERAL EXAMINATION:
Patient is conscious ,coherent , cooperative , oriented to person, time and place
Poorly Built and poorly Nourished .
Temp: Afebrile .
BP : 130 / 90 mmHg
PR : 87bpm
RR : 18 cpm
Pallor : absent
Icterus : absent
Cyanosis: absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
SYSTEMIC EXAMINATION:
CNS :
Higher mental functions
Conscious , oriented to person ,place and time .
Speech : slightly slurred
Memory: intact
Visual hallucinations present
No delusions.
No emotional lability
MMSE 27/30
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
3rd,4th,6th : pupillary reflexes present Restricted range of motion present
Nystagmus present
5th : sensory intact and motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11 th intact
12 th intact
MOTOR EXAMINATION:
Right Left
UL LL. UL LL
BULK Normal Normal Normal Normal
TONE normal normal normal normal
POWER 5/5 5/5 5/5 5/5
Reflexes
BICEPS present
TRICEPS present
SUPINATOR present
KNEE present
ANKLE present
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch normal
pain normal
temperature normal
DORSAL COLUMN SENSATION:
Fine touch normal
Vibration normal
Proprioception normal
Rombergs sign positive
CEREBELLAR EXAMINATION:
Slight tremors present
Truncal ataxia present
Gait ataxia present
Finger nose test : slightly altered
Heel knee test : slightly altered
Dysdiadochokinesia absent
Nystagmus present
SIGNS OF MENINGEAL IRRITATION: absent
GAIT:
wide based gait while walking, unsteady with a tendency to fall and swaying towards the sides
unable to perform tandem walking
CVS : apex at normal position ,S1,S2 + ,no murmurs
RS :
Chest shape normal
Trachea central
BAE Present
Normal vesicular breath sounds
P/A :
Soft and Non tender
No organomegaly present
INVESTIGATIONS ( abnormal fundings)
Hemogram
Hb - 12 gm/dl ( normal =13-17 )
Total count - 10,200 ( normal 4000 - 10000)
Lymphocytes- 18 ( normal 20-40)
Pcv - 37.7 ( normal 40 - 50)
RBC count-3.89 million ( normal 4.5 - 5.5 )
Liver function tests
Total bilirubin- 1.32 mg/dl ( normal 0-1)
Direct bilirubin- 0.34 ( normal 0 - 0.2 )
Alkaline phosphate -185IU/L ( normal 53 - 128 )
Renal function test
Creatinine- 1.4 mg/ dl (normal 0.9 - 1.3)
ECHO
Normal sized liver with increased echogenicity and partially distended gallbladder - indicative of grade 2 fatty liver
PROVISIONAL DIAGNOSIS
1. wernickes encephalopathy ( B1 DEFICIENCY)
2. Cerebellar degeneration secondary to alcohol consumption
3. Alcohol withdrawal
Treatment
1. Tab lorazepam 2mg
2. Tab benfothiamine 100mg bd
3. Tab baclofen 20mg od
4. Nicotine gums 2 mg
5. Counselling
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SHORT CASE
A 13 YEAR OLD GIRL WITH JOINT(;KNEE) AND LOWER BACK PAIN PRESENTED YESTERDAY EVENING AT AROUND 4
HOPI
She is second born child of parents married of 3rd degree consanguinity in 2009. All trimesters were uneventful. She was delivered through Caeserean section because of delayed labour pain with birth weight of 3kg.
Immunized till date.
2012
She was asymmtomatic upto age of 3 years, then she developed high grade fever with cough and vomittings. She was diagnosed with Sickle cell anaemia. Sickling test positive and Electrophoresis showed HbS. Blood transfusion were given 1packet.
2013
She developed high grade fever, dry cough and cold. She was diagnosed with Bronchopneumonia. X-ray lower lobe consolidation.
2015
She had recurrent episodes of fever, cough , cold i.e Recurrent Bronchopneumonia- 6 episodes in 3years. Urine culture showed Klebsiella growth.
Blood transfusion till date 4 times.
2016
She developed fever, pain abdomen , myalgia and arthralgia. She improved on medications and thus was discharged.
2019
She came with stomach pain and vomittings. She was diagnosed to have Acute pancreatitis.
2022
She developed stomach which was sudden in onset, gradually progressive, pricking type in epigastrium,aggravates on walking.
She had 2episodes of vomitting- watery, non bilious, projectile. Dark coloured stools and dark urine.
No history of constipation, difficulty in swallowing, burning sensation.
Was managed conservatively and sent home with Medication
She is immunized till date.
2023
Patient complains of pain in both knees since yesterday morning along with a stabbing type of back pain.
PAST HISTORY
Known case of Sickle cell Anemia.
History of Bronchopneumonia.
History of 8 PICU admissions.
Previous blood transfusions.
No history of Asthama, Thyroid Tuberculosis, Hypertension, Diabetes, Epilepsy
Personal history
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder movements regular
No addictions
FAMILY HISTORY
Pedigree chart
3rd degree consanguity of parents
No known affected relatives
GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative. Well oriented to time, place and person.
Pallor present
Icterus absent
Cyanosis, clubbing, lymphadenopathy, Pedal edema absent
Vitals
Temp: aFebrile
PR- 96Min
RR- 18/Min
BP- 110/70 mmHg
SYSTEMIC EXAMINATION
P/A - Shape of abdomen- Normal. Umbilicus everted. No scars. No organomegaly. Bowel sounds heard.
CVS- S1 S2 heard, no murmurs
RS- NVBS.
CNS- NFND
Tone, power and reflexes are normal.
INVESTIGATIONS
( Done previously at our hospital to confirm diagnosis of sickle cell anemia)
Diagnosis
1. Vasocclusive crisis of sickle cell anemia
2.osteomyelitis / osteonecrosis secondary to sickle cell anemia
