42 M with alcohol withdrawal seizures with alcoholic liver disease
This is online E log book to discuss out patients de-identified health data shared after taking his / her guardian`s informed consent. Here we discuss our individual patient`s problems through series of inputs from available global online community of experts with an aim to solve patients clinical problems with collective current best evidence based inputs.
This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box is welcome .
Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.
Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.
Dr. Sarbesh Mishra
Roll no.: 142
This is the case of a 42 year old male, farmer by occupation and a resident of nalgonda who came to the casuality with the chief complaints of:
Vomiting since 1 week
Involuntary movements of B/L upper and lower limbs 1 day ago.
HOPI:
Patient has history of seizures, upto 10 episodes in the past 5 years.
The first such episode occured when he was driving a tractor in his field.
Patient started having multiple episodes of vomittings since the past week, around 3-4 episodes per day, non billious, non projectile.
1 episode of blood tinged vomitting 1 day ago.
The patient had involuntary movements of bilateral upper and lower limbs 1 day ago. These movements lasted around 5 minutes and were associated with tongue biting and uprolling of eyes. No history of urinary or feacal incontinence. Froth was blood tinged.
No history of fever, loose stools, abdominal pain, giddiness.
Last binge drink lasted 15 days and ended day before yesterday.
Similar complaints of alcohol intake associated seizures present, with around 10 episodes of seizures in the past 5 years.
PAST HISTORY:
Similar complaints present in the past.
N/K/C/O DM,HTN, TB, CAD, CVA, Asthma, Thyroid disorders.
SURGICAL HISTORY:
No relavent surgical history
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep: Normal
Bowel: regular
Bladder: normal
Habits: consumed alcohol regularly from 22 years of age. 1-2 Quarters per day, last alcoholic binge lasted 15 days ended on 4/8/23.
SOCIAL HISTORY AND DAILY ROUTINE:
The patient is a paddy farmer by occupation and drives a tractor.
The patient wakes up by around 5 am. He has rice for break fast if at all at around 7 am. He then goes to work in his field. He has lunch around 2 pm once again consisting of rice and curry. He then goes back to work. He comes back home and has dinner around 7 pm and goes to bed by 8 pm.
The patient continued to work in his field and drive his tractor during the past 5 years.
GENERAL EXAMINATION:
The patient was examined after taking consent in a well lit room.
The patient was conscious, coherent and cooperative.
He is moderately built and nourished.
Pallor: Absent
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
Edema: Absent
Vitals:
PR: 94 BPM
RR: 16 cpm
BP: 130/80mmHg
SpO2: 98%
Temperature: 98.4°F
GRBS: 96 mg/dl
CLINICAL IMAGES:
.jpg)
SYSTEMIC EXAMINATION:
CVS:
On inspection:
Precordium is normal
Apex impulse could not be seen
No visible pulsations
On palpation:
Apex beat localised to 5th intercostal space medial to mid clavicular line.
No parasternal heave
No palpable thrills
On auscultation:
S1 and S2 heard.
No cardiac murmurs heard
RS:
On inspection:
Chest shape is elliptical
Exapands equally on inspiration
Trachea: central
On palpation:
Tactile vocal fremitus is equal in all areas
On percussion:
Resonant note on all regions.
On auscultation:
Bilateral air entry positive
Vesicular breath sounds are heard.
No adventitious sounds such as crepts, rochi, etc heard.
ABDOMEN:
On inspection
Abdomen is scaphoid.
Umbulicus is central and inverted
No scars or sinuses
On palpation:
Abdomen is soft
No tenderness
No organomegally.
On auscultation:
Bowel sounds heard.
CNS:
Cerebellar functions normal.
Cranial nerve examination normal.
Sensory examination: Normal
Motor examination:
Tone: R. L
UL. N. N
LL. N. N
Power:
UL. 5/5 5/5
LL. 5/5 5/5
Reflexes:
Biceps. ++. ++
Triceps. ++. ++
Knee. ++. ++
Ankle. +.+
INVESTIGATIONS:
Comments
Post a Comment