1801006045 CASE PRESENTATION

LONG CASE

A 25 years olf man resident of nalgonda,auto driver by occupation came to medicine opd with cheif complaints of tremors and unstable gait from past 10 days

History of present illness (HOPI) :-

Pt was apparently asymptomatic 12 years back then he began to consume alcohol about 1 to 2 glasses a day and in next few months he drank about 4 to 5 glasses a day for 5 years

After 5 years he switched from alcohol to whisky, he drinks about 50ml per day and recently he started to drink about 300ml from past 2 months

Pt has tremors and pins and needle sensations ..

Pt has habit of chewing tobacco since 9 years about 1 packet every 2 to 3 days

Negative history:-

No history of any head injury in past

No history of fever vomiting or stiffness of neck

No history of any psychiatric condition

No history of any loss of consciousness

Daily routine:-

Pt daily wakes up at morning 5 'o' clock and completes his routine work like fresh up, etc

He then consumes small glass of alcohol and goes to work (auto driver)

Then he comes back to home at 2 pm for lunch following which he consumes 1 to 2 glasses of alcohol and goes back to work

He returns to home at 9 for dinner and sleep..

PAST HISTORY:-

Not a known case of hypertension, tuberculosis, diabetes mellitus, asthma, Epilepsy, cad

PERSONAL HISTORY:-

Diet- mixed

Appetite:- Normal

Sleep- Adequate

Bowel and bladder: Regular

Addictions- alcohol consumption from past 11 years

Tobacco from past 9 years

No allergies

GENERAL EXAMINATION:-

Pt is conscious coherent and co-operative

Moderately built and nourished

No pallor , icterus , cyanosis Clubbing lymphadenopathy oedema

VITALS:-

PR:- 80bpm

Temp- Afebrile

Respiratory rate-16cpm

B.P:- 130/ 80 mm hg

SYSTEMIC EXAMINATION:-

CNS- Higher mental functions:- Pt is conscious coherent and co-operative

Memory is intact

No delusions

Slurred Speech

MMSE SCORE- 26/30

CRANIAL NERVE EXAMINATION-

olfactory nerve

function- Normal

Optic nerve- visual acuity is normal

3rd 4th 6th nerves- Pupillary Reflexes are present

Trigeminal nerve : sensory and motor intact

7th nerve functions : normal

8th nerve : No abnormality noted.

9th,10th nerve : palatal movements present and equal.

11 th intact and 12 th nerves are 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

KNEE present

ANKLE present

SENSORY EXAMINATION:

SPINOTHALAMIC SENSATIONS:

Pain- normal

Crude touch : normal

Temperature : normal

DORSAL COLUMN SENSATION:

Fine touch normal

Vibration normal

Proprioception normal

Rombergs sign negative

CEREBELLAR EXAMINATION:

Slight tremors present

Gait ataxia present

Finger nose test : slightly altered

Heel knee test- slightly altered

Dysdiadokinesia- Absent

Nystagmus- present

GAIT:

Broad based gait while walking,

It is unsteady with tendency to fall and swaying towards the sides

CVS :

S1,S2 heard

No murmurs heard

Respiratory system:

Chest shape - normal

Trachea- central

Normal vesicular breath sounds are heard

P/A examination:

It is Soft and Non tender

No organomegaly

INVESTIGATIONS

Hemogram - RBC count-3.89 million ( normal 4.5 - 5.5 )

Hb-12 gm/dl(normal =13-17)

Pcv - 37.7 ( normal 40 - 50)

Liver function tests :-

Alkaline phosphatase -185IU/L ( normal 53 - 128 )

Total bilirubin- 1.32 mg/dl

( normal 0-1)

Direct bilirubin-0.34

( normal 0 - 0.2 )

Renal function tests:-

Creatinine- 1.4 mg/ dl

(normal 0.9 - 1.3)

PROVISIONAL DIAGNOSIS:-

Alcohol induced wernickes encephalopathy, cerebellar degeneration and Alcohol withdrawal

TREATMENT-

Nicotine gums

Baclofen

Benfothiamine

Tab Lorazepam

Counselling

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SHORT CASE

A 59 yr old male patient came to OPD with cheif complaints of B/L pedal edema and shortness of breath since 3 months

HOPI: patient was apparently asymptomatic 3 months ago then he developed B/L pedal edema which is pitting type which is aggravated towards end of the day and subsides in morning and shortness of breath(Grade:2) and He also has Periorbital puffiness for which he went to private hospital in suryapet and used medication prescribed by them but he was not satisfied then he went to NIMS in Hyderabad 15 days ago for which they diagnosed him with chronic renal failure and done 2 rounds of heamodialysis,the patient came to us for follow up,he is undergoing heamodialysis in our hospital.

PAST HISTORY:

He is a known case of hypertension and Type 2 Diabetes mellitus since 12 years.

He is not a K/C/O TB,asthma, epilepsy,thyroid disorders.

PERSONAL HISTORY:

Diet-Mixed

Appetite-Normal

B and B movements- Regular

Sleep- Disturbed

No addictions

DAILY ROUTINE: Patient is shop vendor by occupation, he wakes up by 7 to 7:30am in mrng and does his personal activities and has breakfast at 9am and goes to his shop and comes to home for lunch at 1 Pm and after having lunch sleeps upto 3.30 pm and wakes up and goes to shop and returns to home for dinner around 8 pm and then he watches Tv and do conversations with neighbours upto 10 pm then he goes to sleep.

TREATMENT HISTORY: pt is on antihypertensives and Oral hyperglycemic agents.

FAMILY AND ALLERGIC HISTORY: No relevant history

GENERAL EXAMINATION:

Patient was conscious, cooperative,well oriented to time,place , person.Moderately built and nourished.

PALLOR WAS PRESENT

NO CYANOSIS

NO ICTERUS

NO CLUBBING

NO GENERALISED LYMPHADENOPATHY

NO EDEMA

VITALS::

TEMP AFEBRILE