46M Uncontrolled DM ; ADS ; TDS
Case History and Clinical Findings
C/O SPASM OF FINGERS OF UPPER LIMBS WITH TREMORS SINCE 3DAYS ,EXCESSIVE SWEATING AND GENERALIZED WEAKNESS SINCE 3DAYS .
PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK ,THEN HE STARTED BINGE DRINKING AND SINCE 3DAYS HE DEVELOPED SPASM OF FINGERS OF UPPER LIMB WITH TREMORS . H/O SWEATING PRESENT . H/O ANXIETY IS PRESENT .
NO H/O CHEST PAIN AND PALPITATIONS , ORTHOPNEA,PND
NO H/O VOMITINGS,ABDOMINAL PAIN ,DIARRHEA .
H/O COUGH WITH EXPECTORATION ,WHITISH IN COLOR SINCE 10 DAYS INCREASED IN SUPINE POSITION .
K/C/O TOBACCO DEPENDENCY SYNDROME
K/C/O DM 2 SINCE 6 YRS
NOT A K/C/O HTN,CVA,CAD,TB,EPILEPSY .
H/O 2 UNITS OF BLOOD TRANSFUSION
H/O SURGERY FOR PANCREATITIS
PERSONAL HISTORY
APPETITE LOST SINCE 10 DAYS
DIET MIXED
BOWEL AND BLADDER REGULAR
OCCASSIONAL ALCOHOLIC
SMOKING TOBACCO SINCE 15 YRS WITH 10 CIGGARETES PER DAY
GENERAL EXAMINATION
PT IS CONSCIOUS,COHERENT ,CO OPERATIVE
NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,OEDEMA
VITALS
TEMP : 99 F
BP : 130/80 MM HG
PR : 86 BPM
RR : 20 CPM
SYSTEMIC EXAMINATION
CVS : S1,S2 HEARD
CNS : NO FOCAL NEUROLOGICAL DEFICIT
RS : BLAE +
P/A : SOFT,NON TENDER
PSYCHIATRY REFERAL ON 11/7
ADVICE : LFT
TREATMENT
TAB.LORAZEPAM 2MG [1-1-2]
TAB BACLOFEN XL 20 MG [X-X-1]
TAB.NALTREXONE 50 MG [1/2 -X-X]
TAB.BENFOTHIAMINE 100MG [X-1-X]
NICOTINE GUMS 4MG [1-1-1] /SOS
PSYCHIATRY REFERAL ON 12/7
TREATMENT
TAB.LORAZEPAM 2MG [1-1-2]
TAB BACLOFEN XL 20 MG [X-X-1]
TAB.NALTREXONE 50 MG [1/2 -X-X]
TAB.BENFOTHIAMINE 100MG [X-1-X]
NICOTINE GUMS 4MG [1-1-1] /SOS
PSYCHIATRY REFERAL ON 13/7
TREATMENT
TAB.LORAZEPAM 2MG [1-X-2]
TAB BACLOFEN XL 20 MG [X-X-1]
TAB.NALTREXONE 50 MG [1/2 -X-X]
TAB.BENFOTHIAMINE 100MG [1-X-1]
NICOTINE GUMS 4MG [1-1-1] /SOS
PSYCHIATRY REFERAL ON 14/7
TREATMENT
TAB.LORAZEPAM 2MG [1-X-2]
TAB BACLOFEN XL 20 MG [X-X-1]
TAB.NALTREXONE 50 MG [1/2 -X-X]
TAB.BENFOTHIAMINE 100MG [1-X-1]
NICOTINE GUMS 4MG [1-1-1] /SOS
PLANNING ON TAPERING DOSE OF LORAZEPAM
Provisional Diagnosis:-
UNCONTROLLED SUGARS WITH ALCOHOL DEPENDENCY SYNDROME
TOBACCO DEPENDENCY SYNDROME
Investigation:-
RBS - 252 MG/DL
HBA1C - 7.2 %
FBS: 140 MG/DL
PLBS : 364 MG/DL
RFT
UREA -16
CREATININE-0.7
CA- 9.6
NA- 137
K-4.1
CL-100
LFT
TB-1.09
DB-0.39
SGOT-18
SGPT-10
ALP-132
TP-5.9
ALBUMIN-3.98
A/G-2.07
ON 11/7
HEMOGRAM
HB- 14.1
TLC - 11,400
N/L/E/M/B - 46/44/1/9/0
PCV -40.4
PLC -3.65 LAKH/CUMM
USG ABDOMEN
GRADE 1 FATTY LIVER
ON 12/7
2D ECHO
NO MR/AR/TR
NO RWMA .NO MS/AS
2D ECHO ON 12/7/2023
NO MR AR TR , NO RWMA ,NO AS/MS
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION ,NO PAH/PE.
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION + ,NO PAH/PE
ON 13/7
HEMOGRAM
HB - 15.6
TLC - 9,200
N/L/E/M/B- 50/42/1/7/0
PLC - 3.48 LAKH/CUMM
Treatment Given:-
INJ HAI SC/BD
INJ NPH SC/BD
TAB.LORAZEPAM 2MG PO/TID
TAB BACLOFEN XL 20 MG PO/OD
TAB.NALTREXONE 50 MG PO/OD
TAB.BENFOTHIAMINE 100MG PO/OD
NICOTINE CHEWING GUM 4MG PO/TID OR SOS
TAB METFORMIN 500 MG PO/TID
8AM-2PM-8PM
TAB GLIMEPERIDE 1.5 MG PO/BDAFTER FOOD INTAKE
TAB THIAMINE 100 MG PO/BD 8 AM-X-8PM
TAB BACLOFEN XL 20 MG PO/OD
X-X-1
COURSE IN THE HOSPITAL ;
PATIENT CAME WITH ABOVE COMPLAINTS WAS ADMINISTERED THIAMINE SUPPLEMENTATION . GRBS WAS MONITORED AND ANTIDIABETIC MEDICATION WAS CHANGED FROM INSULIN TO ORAL ANTIHYPOGLYCEMIC S AND PSYCHIATRY REFERRAL WAS TAKEN FOR HIS TOBACCO AND ALCOHOL DEPENDANCE ,TAB LORAZEPAM ,TAB NALTREXONE , NICOTOINE GUMS, WERE ADMINISTERED WITH THE ABOVE TREATMENT PATIENT WAS STABILIZED AND DISCHARGED AND IN A HEMODYNAMICALLY STABLE STATE.
