1801006053 - LONG CASE
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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
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