A 40 year old male patient with altered state of consciousness

Medical case disscussion 



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Name : Mounika 7th sem 

Roll no : 46


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

A 40 year old male patient with altered state of consciousness 

A 40 year old male a resident of yadhadri , auto driver by occupation got admitted to the hospital on 13-11-21 with 

●Chief complaints of

Presented to casuality in  unconsciousness state
And history of seizure activity yesterday night

●HISTORY OF PRESENT ILLNESS 

Patient consumes alcohol from age of 20 even before marriage  , his wife reports that post marriage he consumed alcohol thrice in a week
Quantity- 90ml ,over the duration of approximately 9years and after that he started drinking daily over a duration of  9 years and she  guessed the quantity to be 360ml[12 units] of whiskey  and from past 1 month he started drinking alcohol during the day approx 3 times

She reports that if the patient doesn't drink any day he would experience excessive sweating, tremors, palpitations 

She reports patient history of seizures from age of 17 years and had a few episodes (7to8)
Last episode was 15 days back when he didn't consume alcohol but reports he had episodes even when in intoxicated state

Episodes used to be associated with LOC , unrolling of eyes,frothing, tonic clinical movements

Reports No history of blood in stools, vomitus,jaundice, head injury, suspiciousness, self talking,self smiling,Loco mood, over valued ideas ,grandiosity, suicidal thoughts, over ritual,repeatative thoughts, forgetfulness 

●PAST HISTORY : 

No history of Diabetes, Asthama,TB,HTN,Thyroid abnormalities 

FAMILY HISTORY :
No  history of seizures in siblings 
●PERSONAL HISTORY :
 
Diet    : Mixed
Appetite: Normal
Sleep  : Adequate
Bowel&Bladder Mvts: Regular
Addictions : Alcohol since 20 years


●DRUG HISTORY :

Phenytoin.I.p 100mg  

●GENERAL EXAMINATION :

Pallor- No
Icterus - No 
Cyanosis - No
Clubbing of fingers/toes- No
Lymphedenopathy - No
Oedema - No

VITALS
        Temperature - 98.6°F
        Pulse rate - 82/m
        Respiratory rate - 22/m
        BP - 120/80
        SPO2 - 96%
        GRBS - 112mg/dl

●SYSTEMIC EXAMINATION :
     Cardiovascular system 
            Thrills - No
            Cardiac sounds- s1 ,s2 heard
            Cardiac murmurs- absent 

      Respiratory system 
             No Dyspnoea
             No  wheeze
             Position of Trachea- central
             Breath sounds-vesicular 
             Adventitious sounds-Rales

       Abdomen
             Scaphoid in shape
             Not tender
             Non palpable 
             Hernias orifice  is normal
             No free fluid present
             No bruins
             Liver - not palpable
             Spleen - not palpable
             Bowel sounds - present


      Central Nervous system 
             Level of consciousness-conscious,alert
             Slurred speech
             Signs of meningitis irritation
                   Neck stiffness- No
                    Kerning's sign- No


●INVESTIGATIONS :



Haemogram 
Hb-15.9
TLC - 7100
Neutrophil -87
Lymphocyte -05
Platelet -3.11
Blood urea -18 
Serum creatinine - 0.6
Serum electrolytes 
Sodium -146
Pottasium -3.4
Calcium - 98

LFT 
Tb -1.74
dB -0.74
AST -1.059
ALT - 531
AKP - 173
TP - 6.4
Albumin - 4.1
A/G - 1.79

CUE 
Pale 
Clear 
Acidic 
PH - 1.010
Sugar - ++
Albumin - ++
Bile salts - nil 
Bile pigments - nil 
Pus cells - 3-4
Epithelial cells - 2-3
RBC - 1-3

●PROVISNAL DIAGNOSIS :
  
            ?Alchoholic withdrawal seizures 

●TREATMENT :
   Inj Thiamine 100ml I.V
   Inj Eptoin 100mg I.V
   Inj PAN 100mg I.V
   Inj Loraz 2c.c I.V

           NS  
   IVF         100ml/hr
           RL

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