A 45 YRS OLD MALE PATIENT WITH ALTERED SENSORIUM
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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
CASE REPORT
A 45 yrs old male patient who was a agriculture labourer by occupation ( worked as a lorry driver 4 yrs ago ) , was brought to casualty with c/o ;
- altered sensorium since today morning (4/8/23)
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 3 days back, then he developed yellowish discolouration of eyes for which he took herbal medication and stopped alcohol abruptly (the patient was a chronic alcoholic since 35 yrs , he drinks ~180ml whiskey per day). From today (4/8/23) morning the patient was unable to speak and was unable to recognise his relatives.
H/O withdrawal seizures 4 yrs ago (1 episode ).
NO H/O fever, pain abdomen, vomitings and loose stools.
PAST HISTORY :
H/O similar complaints in the past 3yrs ago, he had abdominal distension and at that time the patients bilirubin levels was ? 30 according to attenders and for this he was admitted in hospital, got discharged (don't know exactly what was the treatment given). Then he started using herbal medication. Patient stopped drinking for 2 yrs then since 1 yr he started again.
Not a known case of HTN , DM , CAD , CVA , epilepsy, TB , Asthma.
PERSONAL HISTORY:
Diet - Mixed
Appetite - Normal
Bowel and Bladder Habits - Regular
Habits : Patient is a chronic alcoholic since 35 yrs. He was abstinent for 2 yrs , then again he started alcohol consumption since 1 year ( 16-24 units per day whiskey ).
Tobacco consumption since 35 yrs , in the form of smoking and chewable tobacco (khaine initially 1 packet/ 3-4 days then gradually increased to 1 packet/ 1-2 days). Smoking was stopped 10 yrs back , because of ? lung problem.
DAILY ROUTINE :
Patient wakes up at 4 Am in the morning everyday to feed his cattle and then goes back to sleep. Then he wakes up at 8am , does his morning chores , eat breakfast and goes to work. Then takes lunch a break at around 1 pm , again goes back to work after lunch. Patient completes his work by 5 pm and goes home. Then after he goes out to drink alcohol and he usually don’t eat anything after drinking (just curd rice for dinner ). Whenever the patient feels like drinking he might skip the work and go drink the whole day.
PSYCHO SOCIAL HISTORY :
Patient’s first wife died around 2 5 yrs back due to some health problem. Then he married again. His younger son undergone suicide due to personal issues 4-5 yrs. All these family problems(grief ) has aggravated his alcohol intake.
FAMILY HISTORY :
No H/O diabetes or hypertension in the family.
No significant family history.
GENERAL EXAMINATION :
Patient is Drowsy but arousable , not oriented to time , place and person.
Moderately built and nourished.
Pallor - absent
Icterus - present
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Oedema - absent
VITALS :
Pulse - rate 85 beats per minute , regular rhythm.
Blood pressure - 120/99 mmHg
Respiratory Rate - 16 cycles per minute
Temperature - afebrile
GRBS - 135 mg/dl
SPO2 - 99%
SYSTEMIC EXAMINATION :
PER ABDOMEN :
INSPECTION
- Abdomen Distended
- Umbilicus flat and central
- No visible scars or sinuses
- No visible gastric peristalsis
PALPATION
- No local rise of temperature
- No tenderness
- No organomegaly
PERCUSSION
AUSCULTATION
- Bowel sounds heard
CVS EXAMINATION :
Shape of the chest - elliptical
No visible pulsations
S1 , S2 heard
Apex beat - left 5th intercostal space medial to mid clavicular line.
No murmurs
CNS EXAMINATION :
Patient is Drowsy but arousable
Speech -
Cranial nerves - couldn’t be elicited
Sensory system - couldn’t be elicited
Motor system :
Tone -
Power -
Reflexes - Right Left
Biceps : +++ +++
Triceps : +++ +++
Supinator : ++ ++
Knee : ++ ++
Ankle :
Glasgow coma scale : E4V5M3
Plantar Reflex : Rt- Extensor ; Lt- Flexor
Finger Nose coordination - Couldn’t be
APRAXIA CHARTING :
RESPIRATORY SYSTEM :
Trachea - central
Shape of the chest - elliptical
Expansion of chest - symmetrical
Bilateral air entry present , normal vesicular breath sounds heard.
PROVISIONAL DIAGNOSIS :
L
?HEPATIC ENCEPHALOPATHY / ?DELIRIUM TREMENS SECONDARY TO ALCOHOL WITHDRAWAL.K/C/O ?CLD
TREATMENT :
4/8/23 :
1. IVF - 0.9%NS @50 ml/hr
2.INJ THIAMINE 200 mg in 100 ml NS IV/STAT
3.INJ KCL 40 mEq in 500 ml NS over 5 hrs slow IV/STAT
4.Monitoring vitals
5/8/23 :
Abdominal girth - 84 cms
Input/ output - 700 ml/ 500 ml
Diagnosis :
?WERNICKE’s ENCEPHALOPATHY
?DELIRIUM TREMENS SECONDARY TO ALCOHOL WITHDRAWAL
?HEPATIC ENCEPHALOPATHY.
DECOMPENSATED CHRONIC LIVER DISEASE with THROMBOCYTOPENIA & HYPOKALEMIA.
Treatment :
1.Fluid restriction <1.5 litres per day
2.Salt restriction <2 gms/day
3.INJ THIAMINE 200 mg in 100 ml NS
4.INJ UDILIV 300 mg RT BD
5.TAB RIFAGUT 550 mg RT BD
6.TAB SPIRONOLACTONE 25 mg RT BD
7.SYP LACTULOSE 10 ml RT BD
8.SYP HEPAMERZ 10 ml RT BD
9. 2 Egg whites per day
10. Protein powder 2tsps in 1 glass of water PO TID
11.INJ KCL 2 amp in 100 ml NS over 4-6 hrs hrs slow IV
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