1801006053 - LONG CASE

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input..



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



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 history, clinical findings, investigations and come up with diagnosis and treatment plan .


CHIEF COMPLAINTS :- 

25 yr old male pt complains of tremors and unstable gait from past 10 days 


History of present illness (HOPI) :- 

Pt was apparently asymptomatic 12 years back then he began to consume alcohol about 1 to 2 glasses a day and in next few months he  drank about 4 to 5 glasses a day for 5 years 

After 5 years he switched from alcohol to whisky, he drinks about 50ml per day and recently he started to drink about 300ml from past 2 months 


Pt has tremors and pins and needle sensations ..

Pt has habit of chewing tobacco since 9 years about 1 packet every 2 to 3 days 


Negative history:- 

No history of any head injury in past 

No history of fever vomiting or stiffness of neck 

No history of any psychiatric condition 

No history of any loss of consciousness 

No wasting of limbs 

No weakening of limbs 


Daily routine:- 


Pt daily wakes up at morning 5 'o' clock and completes his routine work like fresh up, etc 

He then consumes small glass of alcohol and goes to work (auto driver) 

Then he comes back to home at 2  pm for lunch following which he consumes 1  to 2 glasses of alcohol and goes back to work 


He returns to home at 9 for dinner and sleep.. 


PAST HISTORY:- 

Not a known case of hypertension, tuberculosis, diabetes mellitus, asthma, Epilepsy, CVD


PERSONAL HISTORY:- 

Diet- mixed

Appetite:- Normal 

Sleep- Adequate 

Bowel and bladder: Regular 

Addictions- alcohol consumption from past 11 years 

Tobacco from past 9 years 

No allergies 


GENERAL EXAMINATION:- 

Pt is conscious coherent and co-operative 

Moderately built and nourished 

No pallor , icterus , cyanosis Clubbing lymphadenopathy oedema 













VITALS:- 

PR:- 80bpm 

Temp- Afebrile 

Respiratory rate- 16cpm 

B.P:- 130/ 80 mm hg 


SYSTEMIC EXAMINATION:- 

CNS- 

Higher mental functions:- 

Pt is conscious coherent and co-operative 

Memory is intact 

No delusions 

Speech is normal 

MMSE SCORE- 26/30 


CRANIAL NERVE EXAMINATION-

olfactory nerve function- Normal 

Optic nerve- visual acuity is normal 

3rd 4th 6th nerves- Pupillary Reflexes are present 

Trigeminal nerve : sensory and motor intact


7th nerve functions : normal


8th nerve : No abnormality noted.


9th,10th nerve : palatal movements present and equal.


11 th intact and 12 th nerves are intact





MOTOR EXAMINATION: 

 Right                            Left

    UL LL                        UL LL

BULK Normal Normal Normal Normal


 TONE normal normal normal normal


  POWER 5/5 5/5 5/5 5/5

 


Reflexes 


   BICEPS present 


   TRICEPS present


   KNEE present


   ANKLE present


SENSORY EXAMINATION:  


SPINOTHALAMIC SENSATIONS:

Pain- normal 

Crude touch : normal

Temperature : normal 



DORSAL COLUMN SENSATION:


Fine touch normal 

Vibration normal

Proprioception normal

Rombergs sign negative


CEREBELLAR EXAMINATION:

Not able to walk along straight line ( tandem walking) 

Slight tremors present

Gait ataxia present 

Finger nose test : slightly altered

Heel knee test- slightly altered 

Dysdiadokinesia- Absent 

Nystagmus- present 

No signs of meningeal irritation 


GAIT:

Broad based gait while walking, 

It is unsteady with tendency to fall and swaying towards the sides

CVS :

 Apex is at normal position 

S1,S2 heard 

No murmurs heard


Respiratory system:    

Chest shape - normal  

 Trachea- central

BAE -Present 

Normal vesicular breath sounds are heard



ABDOMINAL EXAMINATION

➤Shape - Scaphoid, with no distention.


➤Umbilicus - Inverted


➤Equal symmetrical movements in all the quadrants with respiration.


➤No visible pulsation,peristalsis, dilated veins and localized swellings.


 No Local rise of temperature and no localised guarding and rigidity.


➤Abdominal girth :- 78 cms


➤ Bowel sounds present.



INVESTIGATIONS :- 

(Abnormal findings)


Hemogram - 

RBC count-3.89 million ( normal 4.5 - 5.5 )  

Hb-12 gm/dl(normal =13-17gm% ) 

Lymphocytes- 18 ( normal 20-40) 

 Pcv - 37.7 ( normal 40 - 50) 

Chest xray :- 




Liver function tests :- 

Alkaline phosphatase -

185IU/L ( normal 53 - 128 ) 


Total bilirubin- 

1.32 mg/dl ( normal 0-1) 


Direct bilirubin-

 0.34 ( normal 0 - 0.2 ) 



Renal function tests:- 

Creatinine-

 1.4 mg/ dl (normal 0.9 - 1.3)



USG abdomen findings- 

Normal sized liver with increased echogenicity- indicative of grade 2 fatty liver


PROVISIONAL DIAGNOSIS:- 

Alcohol induced wernickes encephalopathy, cerebellar degeneration and grade 2 fatty liver 

Alcohol withdrawal 


TREATMENT- 

Thiamine supplements like benfotiamine 100mg bd 

Nicotine gums 2mg

Counselling 


Comments

Popular posts from this blog

55 yr old male with polycystic kidney disease

23 yr old with pancytopenia/ CBBLE UDHC SIMILAR CASES 

65 year old with multiple ulcers over body