56M with Altered sensorium sec to alcohol withdrawal with HTN and DM 2

DOA -24/1/2023
Discharge Date
Date: 28-01-2023
Ward:MALEMEDICALWARD
 Unit:GENERAL MEDICINE 

Diagnosis
ALTERED SENSORIUM (RESOLVED) SECONDARY TO ALCOHOL WITHDRAWL
K/C/O HYPERTENSION (SINCE 9 YEARS)
K/C/O TYPE II DIABETES MELLITUS( SINCE 9 YEARS)
H/OCEREBROVASCULARACCIDENT9YEARSBACKWITHLEFTHEMIPARESIS SECONDARY TO CHRONIC INFARCT IN RIGHT PUTAMEN AND FRONTAL GYRUS .

Case History and Clinical Findings
PATIENTWASBROUGHTTOTHECASUALTYINSTATEOFSUDDENONSETOFALTERED SENSORIUM SINCE 5AM ON 24-01-23
HOPI : PATIENT WAS APPARENTLY ALRIGHT UNTILL 5AM ON 24-01-23 , HE WOKE UP THEN ANDWENTTOOPENTHEDOORANDHELEANEDONTOTHEDOORANDDIDNOTOPENTHE DOOR. HE THEN PASSED URINE INVOLUNTARILY AND SINCE THEN HE IS NOT RECOGNISING HIS FAMILY MEMBERS .HE IS AGITATED WITH MOVING ALL UPPER AND LOWER LIMBS AND PT IS IN CONFUSED STATE WITH GCS E2V2M4 - E4V4M4-E4V5M6.
NO NECK STIFFNESS
NOH/OLOSSOFCONSCIOUSNESS/VOMITINGS/DEVIATIONOFMOUTH/NOUPROLLINGOF EYEBALLS/NO TONIC OR CLONIC SEIZURES/ TRAUMA/FEVER

PAST HISTORY : PATIENT IS A KNOWN CASE OF DIABETES MELLITUS TYPE 2 USING T METFORMIN500MGPO/OD(ONREGULARMEDICATION)ANDHYPERTENSIONSINCE9 YEARS (FOR HYPERTENSION PATIENT'S ATTENDANT DOESNT KNOW)
PATIENTHADCEREBROVASCULARACCIDENT9YEARSBACKWITHLEFTHEMIPERESIS AND PATIENT RECOVERED NOW WITH MILD WEAKNESS OF LEFT UPPER AND LOWER LIMBS.
NOTAK/C/OASTHMA/EPILEPSY/TUBERCULOSIS/CAD/THYROIDDISORDERS

 PERSONAL HISTORY:
DIET MIXED SLEEPNORMAL
APPETITE NORMAL BOWELCONSTIPATION+ BLADDER NORMAL
ADDICTIONSALCOHOLICSINCE16YEARS,LASTBINGEONNIGHTBEFOREADMISSIONAND NON SMOKER
NOSIGNIFICANTFAMILYHISTORY

 O/E PATIENT ON ADMISSION
ISINALTEREDSENSORIUM GCS E2V2M4
TEMP99.4F PR108BPM RR 22CPM
BP 190/110 MM HGSPO297%ATROOMAIR GRBS 365MG/DL
CVS -S1 S2 HEARD NO MURMURS
RS-BILATERALAIRENTRY+NORMALVESICULARBREATHSOUNDS+ 
P/A -SOFT NON TENDER BOWEL SOUNDS+
CNS:PATIENTISIRRITABLEANDAGITATED INAPPROPRIATE SPEECH
SIGNS OF MENINGEAL IRRITATION CANNOT BE ELICITED
MOTORSYSTEMINCREASEDTONEINBOTHUPPERANDLOWERLIMBS POWER COULDNT BE ELICITED BUT MOVING ALL LIMBS
REFLEXESBICEPTRISUPKNEANKPLA RT ++ ++ ++ ++ + F
LT ++ ++ ++ ++ + F
CEREBELLARSIGNS:CANNOTBEELICITED SENSORY EXAMINATION (BILATERALLY) SPINOTHALAMIC TRACT
CRUDE TOUCH - PRESENT
PAIN - PRESENT
TEMPERATURE-PRESENT POSTERIOR COLUMN
FINE TOUCH - PRESENT
IBRATION (RIGHT AND LEFT) UPPERLIMB - 10SECONDS 10SECONDS UPPERLIMB SUPINATOR - 9SEC 9SEC LOWERLIMB TIBIA - 7SEC 8SEC
LOWERLIMB MEDIAL MALLEOLUS - 6SEC 6SEC
JOINTPOSITION-NOTABLETOTELLNOTABLETOTELL CORTICAL TRACT
GRAPHESTHESIA - PRESENT
STEROGNOSIS - PRESENT
TACTILELOCALISATION-PRESENT O/E ON DISCHARGE
PTISORIENTEDTOTIME,PLACE,PERSON TEMP 99.4F
PR88BPM RR 18CPM
BP 130/80 MM HG
SPO297%ATROOMAIR GRBS 152MG/DL
CVS S1 S2 HEARD NO MURMURS
RSBILATERALAIRENTRY+NORMALVESICULARBREATHSOUNDS+ P/A SOFT NON TENDER BOWEL SOUNDS+
CNS :
MOTOR SYSTEM NORMAL TONE IN BOTH UPPER AND LOWER LIMBS
POWERRL UL 5/5 5/5 LL 5/5 5/5
REFLEXESBICEPTRISUPKNEANKPLA RT ++ ++ ++ ++ + F
LT ++ ++ ++ ++ + F


NO CEREBELLAR SIGNS FINGERTOFINGERTEST FINGER NOSE TEST RHOMBERG TEST
STRAIGHTLEGWALKINGTEST HEEL KNEE TEST

COURSE IN THE HOSPITAL :
ON DAY 1 A 65 YEAR OLD MALE WAS BROUGHT TO THE CASUALTY IN ALTERED SENSORIUMSINCEMORNINGMRIBRAINWASDONESHOWEDHYPODENSEAREASEENIN RT SUPERIOR FRONTAL GYRUS AND RT PUTAMEN SUB ACUTE /OLD INFARCT , FEW HYPODENSE AREAS IN BILATERAL PERIVENTRICULAR WHITE MATTER SUGGESTIVE OF SMALL VESSEL ISCHEMIC DISEASE .AND RYLES TUBE WAS PLACED AND HE WAS MANAGEDCONSERVATIVELYANDASHEWASHYPERTENSIVESINCE9YRSANDDIABETIS MELLITUSTYPE2SINCE9YEARSANDINJHUMANACTRAPIDINSULINWASGIVEN@8AM- 2 PM - 8 PM ACCORDING TO SLIDING SCALE AND ALL ROUTINE INVESTIGATIONS WERE SENT.
DAY2PATIENTWASINALTEREDSTATEBUTLESSAGITATEDTHANYESTERDAY2DECHO WAS DONE WHICH SHOWED
CONCENTRICLVH(1.48CMS)LVCOLLAPSING NO RWMA
MILD TR+ TRIVIAL AR+ NO MR SCLEROTICAVNOAS/MSIASINTACT EF 58%
GOOD LV SYSTOLIC FUNCTION DIASTOLICDYSFUNCTIONNOPE IVC SIZE 1.09CMS
INVIEWOFALCOHOLDEPENDENCEAPSYCHIATRYOPINIONWASTAKENANDTHEY ADVISED INJ LORAZEPAM SOS IF PATIENT IS MORE AGITATED.
DAY3PATIENTWASNORMALTODAYANDHEWASWELLORIENTEDTOTIMEPLACEAND PERSON AND NO COMPLAINTS.
DAY 4 PATIENT'S ORIENTATION IMPROVED AND HE WAS SHIFTED TO WARD AND PSYCHIATRYREVIEWWASDONEANDWASADVICEDFORTAB.LORAZEPAMSOSIF PATIENTISAGITATEDORSLEEPLESS.PATIENTSLEPTWELLANDCOMPLAINEDOF SWAYING BUT CEREBELLAR SIGNS WERE NARMAL AND HE WAS TAKING ORALLY
DAY5PATIENTGAVENOCOMPLAINTSANDWITHSTABLEVITALSHEWASDISCHARGEDIN A HEMODYNAMICALLY STABLE CONDITION

Investigation
MRI BRAIN :
NO ACUTE INTRACRANIAL BLEEDS
HYPODENSEAREASEENINNRIGHTSUPERIORFRONTALGYRUSANDRIGHTPUTAMEN- SUBACUTE/OLD INFARCT
FEWHYPODENSEAREASINBILATERALPERIVENTRICULARWHITEMATTER- SUGGESTIVE OF SMALL VESSEL ISCHEMIC DISEASE
2D ECHO :
CONCENTRICLVH(1.48CMS)LVCOLLAPSING NO RWMA
MILD TR+ TRIVIAL AR+ NO MR SCLEROTICAVNOAS/MSIASINTACT EF 58%
GOOD LV SYSTOLIC FUNCTION DIASTOLICDYSFUNCTIONNOPE IVC SIZE 1.09CMS
USG ABDOMEN:
NOSONOLOGICALABNORMALITYDETECTED ECG :
NORMAL SINUS RHYTHM

Treatment Given(Enter only Generic Name)
IV FLUIDS NS@50ML/HR
RT FEEDS 100ML MILK 4TH HRLY AND 50ML WATER 2ND HRLY
TAB ECOSPIRIN AV (75/10) RT/OD(9PM)
INJ HUMAN ACTRAPID INSULIN S/C ACCORDING TO SLIDING SCALE
INJ THIAMINE 200MG/IV/TID6. INJ LORAZEPAM 2 MG HALF AMPULE/IM/SOS
TAB TELMA 40MG/RT/OD AT 8AM
GRBS 6TH HRLY
BP MONITORING HRLY
I/O CHARTING

Advice at Discharge
PLENTY OF ORAL FLUIDS
TAB GLIMI M1 ONCE DAILY PER ORAL BEFORE BF
TAB THIAMINE 200MG PER ORAL TWICE DAILY AT 8AM AND 8PM FOR 15 DAYS
TAB ECOSPRIN AV75/10MG PER ORAL BED TIME
TAB TELMA 40MG PER ORAL ONCE DAILY AT 8AM
TAB PREGABALIN M 75MG/PER ORAL BED TIME AT 9PM
SYRUP CREMAFFIN PLUS 10ML/PER ORAL BED TIME AT 9PM
PHYSIOTHERAPY DAILY .

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