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 :
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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