medicine case presentation
14/5/20
Hello everyone... I am an intern in medicine department and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties.
(the following case that i have presented has already been discussed by my fellow intern. you can check the same with the link provided at the end of presentation)
CASE DISCUSSION-
A 27 year male electrician by occupation presented to the OPD with the chief complaints of vomitings since 2days.
HOPI-
patient was apparently asymptomatic 4 days back then he started having decreased appetite following alcohol binge (local toddy)
-Two days later he had an episode of seizures, after stopping alcohol.
it was not associated with frothing, loss of consciousness, uprolling of eyeballs, involuntary bowel and bladder movements.
-h/o decreased responsiveness for which he was admitted in local hospital and treated as ?(DELIRIUM TREMENS)
-Later the patient was brought to our hospital with complaints of vomitings since 2days
non-bilious, non-blood stained, not associated with fever, pain abdomen or loose stools.
History of past illness-
-K/C/O CHRONIC ALCHOLIC since 4 years.
(takes about 90-180ml whiskey/day)
-h/o beetle chewer
-no history of tuberculosis, asthma, hypertension, CAD, CVA, epilepsy
PERSONAL HISTORY-
diet-mixed
appetite-decreased (since 4days)
sleep-adequate
B&B-regular
substance abuse- alocholic (Since 4years)
beetle chewing
FAMILY HISTORY-
not significant
-no known food or drug allergies
GENERAL EXAMINATION-
-patient was conscious, coherent and coperative
-moderately built and nourished.
-no signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema
-VITALS
1.temperature-AFEBRILE
2.pulse rate-92bpm
3.respiratory rate-18 cycles/min
4.BP-110/90mmhg
5.SpO2-96%
6.GRBS-91mg/dl
SYSTEMIC EXAMINATION-
I.CVS-
S1 S2 heard
no added murmurs
2.RESPIRATORY SYSTEM-
-normal vesicular breath sounds heard
-bilateral air entry present
3.PER ABDOMEN-
shape=scaphoid
umbilicus=central and normal in position
all quadrants moving equally on respiration
no tenderness
no organomegaly
bowel sounds-heard
no bruit heard
4.CNS-
patient is conscious, coherent, coperative
patient well oriented to time, place and person
higher mental functions= normal
GCS-15/15
Cranial nerves- intact
Motor system- normal
sensory system-normal
No meningeal signs
No cerebellar signs
Based on the above complaints patients blood samples were sent for
1.CBP
2.serology
3.LFT
4.RFT
5.ECG
6.CUE
and after that was sent to psychiatry referral for substance abuse
Dept of psychiatry-
C/O abnormal behaviour since 3 to 4 days characterised by starry looks, episodic irritability, sleeplessness, increased reaction time to the question asked.Started with pain in neck with involuntary movements of head followed by above symptoms taken to outside local hospital treated for hypokalemia.
Substance use history-alcohol intake history mentioned above
Similar episodes were reported 14 days back and 1 year back
O/E conscious oriented sat on chair has starry look etec maintained raport established speech normal, reaction time increased, relevant, coherant
As per history given by patient
DD:1.Prodromal psychosis
2.Alcohol induced psychosis
Rx:1.T.Oleanz 5mg
2.T.Enchorate Chrond 300mg
3.T.Diazepam 5mg
Based on these findings,he was diagnosed with -
Alcohol induced gastritis
with K/C/O delirium tremens and alcohol dependent syndrome
Rx given
1.Inj.pantop 40mg/iv/od
2.Inj.zofer 4mg/iv/bd
3.Inj.thiamine iv/td
4.Inj.optineuron 1amp in 100ml/iv/od
5.Ivf-NS, RL, DNS
6.T.clonazepam 0.25mg
7.I/O charting
8.BP/PR/temperature monitoring.
15/05/2020
went for checking his vitals and to get an EEG done
vitals-
1.temp-afebrle
2.bp-120/90mmhg
3.pulse rate-86bpm
4.respiratory rate-17cpm
5.spO2-99%
EEG was done but results were not issued
here is the link of same case presented by my cointern:
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