A 36 yr old malepresented with altered sensorium

Chief complaint
Patient was brought with cc of abnormal behaviour
History of present illness
Patient was apparently asymptomatic till22 am last night then he started behaving abnormally  which was sudden in onset in terms of not responding when spoken to, irrelevant talk which is repeating and alao self talking behaviour

Patient had history of alcohol consumption since 10 yrs
Currently 6 to 12 units per day daily through out the day
Reports craving for alcohol
Sweating and trembling when he doesnt consume alcohol
As per OD patient didnt consume alcohol  since 15 days till  yesterday
 But was given 3 units yesterday, tremors subsided after consumption. OD also reports seeing double images, slurring of speech at times & memory disturbances  since ten days
Sleep disturbed last night
Not going to work since 3 days
Appetite decreased

History of past illness
H/o head injury one month back associated with bleeding
H/o previous admission in psychiatry in a private hospital for alcohol
(Reports not available )
N/k/c/o Diabetes mellitus, Hypertension, Asthma,CAD, TB
 Personal history
Maritalstatus : married
Occupation : Barber
Appetite : lost
Diet : mixed
Bowels : regular
Micturition: abnormal
Habits:
Alcohol - from 10 yrs
Tobacco - smoking daily
Drug use : No
Betel pan : no
Betel nut : no 

Family history
No relevant history

Physical examination
No pallor, cyanosis, icterus, clubbing of fingers/toes, lymphadenopathy, edema of feet
Vitals
Temperature : 99 F
Pulse rate : 68/ min
Rr:18/min
Bp:120/80 mm hg
Spo2 : 98%
Grbs:96 mg %
Systemic examination
Cvs : s1 s2 +
Respiratory system
Dyspnoea- no
Wheezing - no
Position of trachea - central
Breath sounds- vesicular
Abdomen
Shape of abdomen : scaphoid
Tenderness- no
Palpable mass - no
CNS
Level of consciousness - alert
Speech - now normal ( when admitted it was slurred)

Sogns of meningeal irritation
Neck stiffness: no
Kernig sign : no

Cranial nerves 
1- intact
2- intact 
3,4,6- intact
5- intact
7- intact
8- intact
9,10- intact
11- intact
12
MOTOR SYSTEM
Tone              right             left
Upper limb     normal        normal
Lower limb       normal      normal
Power
                          4/5        4/5
                          4/5        4/5

Reflex    B      T     S      K      A        P
Right      2+    2+   2+     2+   2+      increase 
Left        2+    2+   2+     2+   2+      increase

Cerebellar sign
Finger nose test : -ve
Finger finger test: - ve
Rombergs test : + ve
Dysdiadochokinase - ve
Sensory system is normal


Provisional diagnosis : Alcohol withdrawal delirium
Alcohol dependence syndrome
Investigations

Treatment

    




Comments

Post a Comment

Popular posts from this blog

leg and joint pain

Image
This is online E log book to discuss our patients health data shared after taking his guardians informed consent form I have been given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings  investigations and come with a diagnosis and treatment plan.  This is a case of 14 yr old female diagnosed with Sickle cell anaemia have multiple admissions for sickle cell crisis  now presented  with chief complaints of        - Joint pains more at night         - Right knee pain since 15 days         - left leg shin pain HOPI Patient was apparently asymptomatic 10 yrs back and diagnosed as Sicke cell anaemia with known history of Abdominal pain, yellowish discoloration of eyes,SOB,fever,dry cough, pleural tap  and she had  blood transfusion 15 times since childhood and had multiple episodes of sickle cell crisis  and brochopneumonia  and pancreatitis
Read more

A 33 yr old male

A 33 year old patient resident of Suryapet,electrician by occupation ,presented to casuality with chief complaints of             -Nausea and vomitings since Sunday 4pm           - Epigastric pain since Sunday  2 pm            -Induced vomiting           - Throat pain HISTORY OF PRESENT ILLNESS Patient is Chronic alcoholic since 20yrs. Due to issues with his wife he consumes alcohol since 1 yr.For the last 7 days he is drinking without eating food. He has complaints of Epigastric pain since yesterday ,burning type and radiating to back and gradually progressive. Nausea and Vomiting is seen ( vomitis in black colour)after retching ,non bilious,non projectile Complaints of burning sensation in throat PAST HISTORY Similar episode of binge drinking, 2 episodes in last 1yr N/C/K/O DM K/C/O Hypertension since 5yrs, On medication ,irregular H/O Hernial surgery (Rt) 10 yrs back  PERSONLA HISTORY  - Married  -Mixed diet  -Apettite less since 1yr  -Bowel movements -  Regular  -Micturition - Norm
Read more

A 50 yr old female with anuria

Image
CASE SCENARIO A 50 YR OLD FEMALE WITH ANURIA ★ CHIEF COMPLAINTS  Anuria since 3 days Fever with chills since 3 days SOB grade 3 since 3 days Throat pain with difficulty in swallowing since 1 week ★HISTORY OF PRESENT ILLNESS -Apparently pt was asymptomatic 1 week ago Then she developed few throat ulcers which made her difficult to swallow even water.  -She got treated for it in a local hospital but it did not get cured.  Due to those ulcers, she couldn't even drink nor eat.  -Since 3 days, she developed fever with chills, anuria, SOB Yesterday morning, they visited a govt hospital in suryapet, where they stayed till evening just to know that she was suffering with renal failure and hence the hospital cannot afford to keep them anymore.  -Then they had to immediately shift her to a private hospital in suryapet, who eventually rejected to admit her because of the same unethical reason.  Later, yesterday night by 8pm they reached our hospital.  PAST HISTORY - N/k/c/o DM , HTN , epileps
Read more