1801006020 CASE PRESENTATION
LONG CASE
24 yrs old male came to the medicine OPD with cheif complaint of unstable gait and tremors since 10 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 12 years ago he started drinking alcohol after his mother passed away in a tragic accident , to alleviate that stress.
He started taking alcohol in the form of ARRACK drinking every alternative day about 1-2 glasses a day
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 .
patient also started chewing tobacco since the last 9 years , around 1 packet every 2-3 days
He also complains of sleep disturbances,decreased appetite and sweating if he does not consume alcohol .
Patient has visual hallucinations , pins and needle sensations
His family then enrolled him in a deaddiction programme
no history of any psychiatric conditions .
no history of any head injury .
no history of any loss of consciousness.
no history of any epilepsy.
no fever , vomitings , neck stiffness
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 has a history of fracture to the left arm following an accident, it is 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 was examined after taking consent in a well lit room .
Patient is conscious ,coherent , cooperative , oriented time , place and person .
Poorly Built and poorly Nourished .
Temp: Afebrile
BP : 130 / 90 mmHg
PR : 87bpm
RR : 18 cpm
Pallor : absent
Icterus : absent
Cyanosis: absent
Clubbing : absent
Generalized Lymphadenopathy : absent
Bilateral pedal 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 liability
MMSE score - 27/30
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
3rd,4th,6th : restricted ocular movements .
pupillary reflexes present.
Nystagmus - present .
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11 th : intact
12 th : normal
Motar examination
RT LT
UL LL UL LL
Bulk : Normal Normal Normal Normally
Tone : Normal Normal Normal Normally
Power : 5/5 5/5 5/5 5/5
Reflexes : biceps: present present present
Triceps : present present present
Knee: present present present present
Ankle : present present present present
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch : Normal
pain : Normal
temperature : Normal
DORSAL COLUMN SENSATION:
Fine touch : normal
Vibration : normal
Proprioception : normal
Rombergs sign : negative
https://youtube.com/shorts/Y6CGqh_wrII?feature=share
CORTICAL SENSATION:
Two point discrimination : normal
Tactile localisation : normal
CEREBELLAR EXAMINATION:
Slight tremors are present
Truncal ataxia - present
Gait ataxia - present
Nystagmus- present
Coordination - Finger nose test - slightly altered
Heel knee test - slightly altered
Dysdiadochokinesia - absent
https://youtube.com/shorts/LUSDgPWYsSo?feature=share
GAIT: https://youtube.com/shorts/x0k9rWWj06I?feature=share
wide based gait, swaying to sides ,
Unsteady with a tendency to fall.
unable to perform tandem walking.
SIGNS OF MENINGEAL IRRITATION:
Neck stiffness - absent
Kernigs sign - absent
Brudzinskis sign - absent
CVS :
Apex at normal position
S1 S2 + ,no murmurs
Respiratory system :
chest shape normal
Trachea central
Bilateral air entry Present
Non vesicular breath sounds present
P/A : Soft and Non tender
No organomegaly
Investigations
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 size liver with increased ecogenicity and partially distended gallbladder
Chest x ray:
Provisional diagnosis
1. Wernickes encephalopathy ( vit b1 deficiency)
2. Cerebellar degeneration secondary to alcohol consumption
3. Alcohol withdrawal delirium
Treatment
1. Tab lorazepam 2mg
2. Tab benfothiamine 100mg bd
3. Tab baclofen 20mg od
4. Nicotine gums 2 mg
5. Counselling
75 yrs old male came to the OPD with CC:vomiting since 10 days ,Sob since 20 days Bilateral pedal oedema since 30 days .
HOPI:
Patient was apparently asymptomatic 30 days back then he developed
Bilateral pedal oedema which is insidious in onset, gradually progressive , pitting type , extending from knee to foot , no agrrevating and relieving factors .
Sob which is insidious in onset gradually progressive, grade 4 , agrrevates on walking
Vomiting - 4- 5 / day , non bilious , non blood stained , immediately after taking water and food .
PAST HISTORY
18 yrs back he developed tb for which he had take antitubercular for 6 months and tb symptoms subsided.
Diagnosed as hypertensive 1 month back ( insidental finding )
Not a known case of diabetes , asthma , epilepsy, thyroid.
No history of fever , chills and rigor , burning micturition , decreased frequency of urination .
No history of previous surgery
PERSONEL HISTORY:
75years old male previously he worked as farmer but now he stay in his home patient wake up at 4:30am morning and do his regular activities and he had breakfast with rice and vegetables curry at 7:30am and he stays in home at 1pm he had lunch(rice+vegetables curry)and at 7pm had there dinner(some times chepati,rice,curry) and at 9oclock he sleep
Diet - mixed
Appetite - decreased since 10 days
Sleep - decreased since 10 days
Bowel and bladder - regular
Addictions - consumes alcohol from 30 years of age , 1 quarter daily , stopped 3 months back.
FAMILY HISTORY: no relavent family history.
Treatment history : no treatment history.
GENERAL EXPLANATION:
pt is conscious, coherent, cooperative and we'll oriented with time,place,person
Pallor: present
ICTERUS: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy: absent
Pedal edema: bilateral pedal oedema, pitting type.
VITALS:
TEMP: 97.2 F
PR: 80/min
RR: 22/min
BP: 130/80 mmHg
SYSTEMIC EXAMINATION:
Respiratory system
RESPIRATORY SYSTEM-
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity, nose & oropharynx appears normal.
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear equal on both sides and it's Abdominothoracic type.
Trachea central in position & Nipples are in 5 th Intercoastal space
No signs of volume loss
No dilated veins,sinuses, visible pulsations.
Palpation:-
All inspiratory findings confirmed
Trachea central in position
Apical impulse in left 5th ICS, 1cm medial to mid clavicular line
MEASUREMENTS-
chest circumference
- transverse 28 cm
- AP - 16 cm
Tactile vocal phremitus- present in all areas but reduced in right and left infra axillary and right and left subscapular regions
Percussion:-.
Right left
Supraclavicular- Resonant (R) (R)
Infraclavicular- (R) (R)
Mammary- (R) (R)
Axillary- (R) (R)
Infra axillary- dull dull
Suprascapular- (R) (R)
Interscapular- (R) (R)
Infrascapular- dull dull
Auscultation:-
Right Left
Supraclavicular- Normal vesicular breath sound s (NVBS)
Infraclavicular- (NVBS) (NVBS)
Mammary- (NVBS) (NVBS)
Axillary- (NVBS) (NVBS)
Infra axillarry decreased decreased
Suprascapular- (NVBS) (NVBS)
Interscapular- (NVBS) (NVBS)
Infrascapular- decreased decreased
CVS:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
JVP - Slightly raised
Palpation :
Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs
Per abdomen:
On inspection:
Shape - flat
Abdomen moves equally with respiration.
Umbilicus inverted
No scars and sinuses present.
No visible pulsatios , no engorged veins
On palpation:
No tenderness
No rebound tenderness, no gaurding, no rigidity
No organonegaly
On percussion:
No fluid thrill
No shifting dullness
On Auscultation:
Bowel sounds heard
CNS:NO focal neurological deficit
INVESTIGATION:
X ray
1)USG:
Impression- grade 3 Rpd of right kidney
Grade 2 Rpd of left kidney
Bilateral pleural effusion - left is more than right side
2) HEAMOGRAM:
Hb - 7.4 gm/ dl
Lymphocytes- 15 %
Pcv - 24.3 vol%
Mchc -30.5 %
RBC - 2.41 million/cumm .
Platelet count - 90,000
Smear -
normocytic hypochromic with anisopokilocytosis
Macrocytes , macro ovalocytes seen
Platelets count reduced on smear .
Impression - dimorhic anemia with thrombocytopenia.
3) COMPLETE URINE EXAMINATION:
COLOR : pale yellow
Appearance - clear
Specific gravity- 1.018
Albumin +
Pus cells 2-4
Epithelial cells 2-3
4) Serum electrolytes
Sodium - 138
Potassium- 3.8
Chloride - 104
Ionized calcium - 0.92
5)SERUM CREATININE: 6.6 mg/dl ( normal 0.7 to 1.1 )
6)BLOOD UREA: 181 mg/dl
Provisional diagnosis
Acute on Ckd, Pleural effusion? IDA?
Treatment
inj LASIK20mg IV BD
CAP BIOD3 PER ORALLY OD
TAB OROFER XT PER ORALLY OD
Tab SHELCAL PER ORALLY OD
INJ ERYTHROPOIETIN 4000IU SUBCUTANEOUS WEEKLY ONCE
14-03-2023
Follow Up
Symptoms subsided
Patient is on regular medication for hypertension.
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