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 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
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