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