04 lasya

                                 

             E-LOGS GENERAL MEDICINE

 

Hi, i am lasya, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. Hope this will be informative!

* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

* Elog made under guidance of Dr.Abhimanyu (Intern)

A 45 year old male who is a chronic alcoholic came to the casualty with involuntary movements of upper and lower limbs.

CHIEF COMPLAINTS:

*c/o 3 episodes of GTCS i;e today morning 1-2am , each episode lasted for 2-3mins , postictal confusion for 5-10mins

*Uprolling of eyeballs, tounge bite +

*No involuntary micturation and no other complaints.

*h/o 2-3 episodes vomiting after seizure activity

HISTORY OF PRESENT ILLNESS:

No h/o fever 

Alcohol consumption since 20 years(daily drinking since 7 years) , increased since last 2 years , binge drinking since 4 days , last drank yesterday.

Patient was apparently asymptomatic 20 years back , then he started consuming whiskey initially would drink 90ml / day in a social gatherings along with friends and relatives.

OD reports that patient has been drinking daily since last 6 years , eyeopener + since 2 years , lends money from people to consume alcohol , was abstinent from alcohol during lockdown period and experienced sleep disturbances for 3 days which subsided on its own

Average consumption of alcohol 360ml per day(8units)

Patient reports to experience sleep disturbances , fearfulness , palpitations and sweating if he does not consume alcohol.

Denies any stressers. h/o seizure episode 3 years back associated with LOC , uprolling of eyes , tonic clonic movements with postictal confusion of 30 minutes. Patient was intoxicated state when he had this episode.

Patient had another episode of seizure yesterday at 4am which was associated with loss of consious ness , uprolling of eyes , tonic clonic movements which lasted for 20minutes.

h/o chewing tobacco since 6 years. Chews about 2-3 packets per day. Reports to experience headache , irritability if he doesn't chew tobacco , despite knowing the harmful effects of tobacco.

h/o head injury 1 year back , not associated with vomitings/LOC. Patient was in intoxicated state and fell on the road.

h/o jaundice 3 years back , no h/o black coloured stools , blood in vomitus , pervasive low mood , suspiciousness , grandiosity , repetitive thoughts , other substance use.

HISTORY OF PAST ILLNESS;

k/c/o DM since 3 years and on regular medication.

 h/o seizure episode 3 years back and hence was admitted for the same.

TREATMENT HISTORY:

Tablet GLIMY M1 OD since 2 years for DM 

PERSONAL HISTORY:

Married 

Appetite-normal (non-vegetarian)

Bowels - regular , micturation-normal , no known allergies

Addictions-Regular alcoholic , chewable tobacco , betel leaf

FAMILY HISTORY:

Not significant

MSE:

GAB:Patient was lying on the bed. IV connected. Responding to oral commands.

ETEC+ Sustained , rapport-established , tremors+ (mild) 

PHYSICAL EXAMINATION:

Pallor-not seen

Icterus-not seen

Cyanosis-not seen

Clubbing-not seen

Lymphadenopathy-not seen

VITALS:

Pulse Rate-84bpm

BP-140/80mm Hg

SYSTEMIC EXAMINATION:

1.CVS

     *S1 and S2 heard

2.RESPIRATORY SYSTEM:

     *BAE + , NVBS

3.ABDOMEN

     *Soft , NT

4.CNS:

     *NFND

PROVISIONAL DIAGNOSIS:

GTCS Secondary to metabolic 

?Hypoglycemia

?Alcohol intoxication

INVESTIGATIONS:

1)USG DOPPLER

2)RFT 07-08-2021 05:22:AM

* UREA 25 mg/dl (42-12 mg/dl)

* CREATININE 0.8 mg/dl (1.3-0.9 mg/dl)

* URIC ACID 9.2 mg/dl (7.2-3.5 mg/dl)

 *CALCIUM 10.1 mg/dl (10.2-8.6 mg/dl)

* PHOSPHOROUS 3.7 mg/dl (4.5-2.5 mg/dl)

* SODIUM 134 mEq/L (145-136 mEq/L)

* POTASSIUM 4.0 mEq/L (5.1-3.5 mEq/L)

* CHLORIDE 97 mEq/L (98-107 mEq/L)

3) LIVER FUNCTION TEST (LFT) 07-08-2021 05:22:AM

* Total Bilurubin 2.64 mg/dl (1-0 mg/dl)

 *Direct Bilurubin 0.42 mg/dl ( 0.2-0.0 mg/dl)

* SGOT(AST) 32 IU/L (35-0 IU/L)

* SGPT(ALT) 15 IU/L (45-0 IU/L)

 *ALKALINE PHOSPHATE :

200 IU/L (128-53 IU/L)

* TOTAL PROTEINS 7.2 gm/dl (8.3-6.4 gm/dl)

 *ALBUMIN 3.9 gm/dl (5.2-3.5 gm/dl)

 *A/G RATIO 1.24

TREATMENT GIVEN:

7/8/21(8am)

1) Inj.LEVIPIL 500mg IV/BD

2) Inj.THIAMINE 1amp in 100ml NS IV/TID

3) Inj.OPTINEURON 1amp in 100ml NS IV/OD

4) Inj.PAN 40mg IV/OD

5) Inj.ZOFFER 4mg IV/TID

6) Inj.LORAZ 2cc IV/SOS

7) GRBS monitoring 2nd hourly

8) W/F seizure activty

9) BP/PR/Temp/spo2 monitoring

10) Inj 5% DEXTROSE IV infusion @ 100ml per hour

DISCHARGE SUMMARY:  

Discharge type : relieved 

Discharge date :9/8/21

Name of treating faculty: 

DR BHAVYA SREE (INTERN)

DR ABHIMANYU (INTERN)

DR RAAGA MEGHANA (INTERN)

DR SAI DEEPIKA (INTERN)

DR NIKHILESH KRISHNA (INTERN)

DR VAMSI KRISHNA PGY1

DR RASHMITHA PGY2

DR NIKITHA PGY2

DR HAREEN (SR)

DR ARJUN KUMAR (AP)

DR RAKESH BISWAS (HOD)

Diagnosis : 

GTCS SECONDARY TO ALCOHOL INTOXICATION

case history and clinical findings :

C/O EPISODES OF GTCS SINCE TODAY MORNING AT AROUND 1-2AM,EACH EPIOSODE

LASTING FOR 2-3 MIN WITH POSTICTAL CONFUSION FOR 5-10MIN ASSOCIATED ITH

UPROLLING OF EYE BALLS AND TOUNGE BITE IS PRESENT.

NO FROTH/INVOLUNTARY MICTURITION

NO OTHER COMPLAINTS

H/O 2-3 EPISODES OF VOMITING AFTER SEIZURE ACTIVITY

NO H/O FEVER

THE PATIENT IS CHRONIC ALCOHOLIC SINCE 20 YEARS AND STARTED TAKING MORE

AMOUNT OF ALCOHOL SINCE LAST 2 YEARS AND HE HAD BEEN BINGE DRINKING FROM

PAST 4 DAYS AND LAST DRINK WAS TAKEN YESTERDAY

K/C/O DM SINCE YEARS AND IS ON GLMI-M1

H/O SIMILAR COMPLAINTS 2 YEARS BACK

NO SIGNIFICANT FAMILY HISTORY

VITALS : 

TEMP- 97.4 F

PR- 80 BPM

RR- 20 CPM

SPO2- 98% AT RA

SYSTEMIC EXAMINATION :

CVS- S1S2 HEARD

RS- BAE + , NVBS HEARD

P/A- SOFT, NT

CNS- NFND

Investigations : 

1)USG DOPPLER

2)RFT 07-08-2021 05:22:AM

* UREA 25 mg/dl (42-12 mg/dl)

* CREATININE 0.8 mg/dl (1.3-0.9 mg/dl)

* URIC ACID 9.2 mg/dl (7.2-3.5 mg/dl)

 *CALCIUM 10.1 mg/dl (10.2-8.6 mg/dl)

* PHOSPHOROUS 3.7 mg/dl (4.5-2.5 mg/dl)

* SODIUM 134 mEq/L (145-136 mEq/L)

* POTASSIUM 4.0 mEq/L (5.1-3.5 mEq/L)

* CHLORIDE 97 mEq/L (98-107 mEq/L)

3) LIVER FUNCTION TEST (LFT) 07-08-2021 05:22:AM

* Total Bilurubin 2.64 mg/dl (1-0 mg/dl)

 *Direct Bilurubin 0.42 mg/dl ( 0.2-0.0 mg/dl)

* SGOT(AST) 32 IU/L (35-0 IU/L)

* SGPT(ALT) 15 IU/L (45-0 IU/L)

 *ALKALINE PHOSPHATE :

200 IU/L (128-53 IU/L)

* TOTAL PROTEINS 7.2 gm/dl (8.3-6.4 gm/dl)

 *ALBUMIN 3.9 gm/dl (5.2-3.5 gm/dl)

 *A/G RATIO 1.24

TREATMENT GIVEN (Enter only Generic Name)

1.INJ.THIAMINE 1AMP IN 100ML NS IV/TID

2.INJ.OPTINEURON 1AMP IN 100ML NS IV/OD

3.INJ.PAN 40MG IV/OD

4.INJ.5% DEXTROSE IV INFUSION@100ML/HR

5.GRBS MONITORING

6.BP/PR/TEMP/SPO2 MONITORING

7.INJ.ZOFER 4MG IV/TID

8.IN.LORAZ 2CC SOS/IV

9.W/F SEIZURE ACTIVITY

10.INJ.LEVIPIL 1GM IV/STAT ---F/B--> 500MG IV/BD

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS

THANK YOU