A 30 year old male

 This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including histoty, clinical findings, .investigations and come up with a diagnosis and treatment plan. 

DANDU SHIVANI.

INTERN


A 30 year old male patient resident of Gudipally came to the casualty on 23/11/22 of altered behaviour since yesterday

  Involuntary micturition since yesterday

Giddiness since morning

HOPI.

Patient was apparently asymptomatic till 12 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 repetitive and self talking.patient is irritable every few minutes and abuses family members at times.

Patient had history of alcohol consumption since 10 years currently 6 to 10 units daily throughout day,reports craving for alcohol, sweating and trembling when he doesn't consume alcohol.patient stopped consumption for the past 10 days till yesterday but was given 3 units I/v/o tremors

@ 10:30 am which subsided after consumption . patient.also reported double images and slurring of speech and memory disturbances since 10 days.patient reports consumption of tobacco in the form of smoking(10 cigarettes per day).

PAST HISTORY

H/O fall 1 month back ,sustained injury @ head.

N/K/C/O DM,HTN, TB ASTHAMA, EPILEPSY.

FAMILY HISTORY: not significant

PERSONAL HISTORY

DIET: Mixed

APPETITE: decreased

SLEEP: disturbed

BOWEL AND BLADDER MOVEMENTS: regular

ADDICTIONS: alcoholic since 10 years.

ON EXAMINATION.

Patient is conscious.

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema.

Temperature

BP: 120/80 mm hg

PR:68/min

RR:18/ min

SPO2:98% at room air.

GRBS: 98MG/DL.

SYATEMIC EXAMINATION

CNS.

HMF: orientation to place and person present and to time absent.

MEMORY: IMMEDIATE:

SHORT TERM.

LONG TERM:

PUPILS: NSRL

SPEECH: normal.

CRANIAL NERVE EXAMINATION: INTACT

SENSORY SYSTEM NORMAL

MOTOR SYSTEM

                        RIGHT.    . LEFT  

TONE.    UL    Normal      normal

               LL.      Normal.   normal

POWER.  UL.     4/5.           4/5

                    LL.    4/5.           4/5.


REFLEXES.       RIGHT.       LEFT

BICEPS.             2+.                2+

TRICEPS.             2+.                2+

SUPINATOR.       2+.                 2+

KNEE.                   2+.                 2+

ANKLE.                 2+.                 2+

PLANTAR.           2 +.                    2+ 

SENSORY SYSTEM: normal.

CEREBELLAR SIGNS

FINGER NOSE TEST - IN COORDINATION PRESENT

FINGER FINGER TEST- IN COORDINATION PRESENT

ROMBERGS - NEGATIVE

DYSDIADOKINESIA- NEGATIVE

GAIT - NORMAL




CVS examination:

S1, S2 are heard.

No murmurs.

Respiratory system examination:

Inspection: Chest is moving bilaterally symmetrical. No pulsations.

Palpation: Trachea is central in postion.

Percussion: Resonant 

Auscultation: Breath sounds are vescicular.

Abdomen examination:

Inspection: Shape is scaphoid.

                    Movements are equal.

Palpation: No tenderness

                   Normal temperature

                   No organomegaly.

Percussion: Normal.

Auscultation: Bowel sounds heard.

INVESTIGATIONS.



DIAGNOSIS:.

? ALCOHOL WITHDRAWL DELIRIUM

? ALCOHOL WITH DRAWL PSYCHOSIS

? ALCOHOL DEPENDENCE SYNDROME

TOBACCO DEPENDENCE SYNDROME WITH DIABETES MELLITUS AND HYPERTENSION.

TREATMENT:

1.IVF( NS,RL @ 75 ML/ HR

2. INJ THIAMINE 200 MG IV/ TID

3. INJ PAN 40 MG IV /OD/ BBF

4.TAB LORAZEPAM 2 MG PO/BD

5. INJ LORAZ 2 MG/ IM/ SOS

6.BP/ PR/ TEMP CHARTING 6 TH HRLY






















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