60 year old patient with alcohol withdrawal features

 This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.

I've been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

FOLLOWING IS THE VIEW OF MY CASE

CHIEF COMPLAINTS:

Complaints of seizure like activity 2 hours ago. 

Complains of vomiting since yesterday. 

Complains of headache since afternoon

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic two days ago then he had 

1.c/o generalised weakness (h/o binge alcohol, drinking previous night) 

2. decreased appetite

3.Complains of vomiting since 

• yesterday - one episode                                      
• Today- 3 episodes
• Food as content,non mucopurulent, watery, non-blood tinged

4.Patient also has seizure 

•  lasted for 10mins
• all four limbs were rigid
•  upward rolling of eyes
• frothing from mouth
• LOC
• no involuntary micturation or defecation
• Post ictal confusion for 30mins 

5. Complains of a headache 

• bilateral frontal
• no lacrimation
• no photophobia
• Not radiating to back or arms

6. C/o chest pain 

• Dragging type 
• on and off since 10 years. 
• Recently - 1 month ago

7. C//O Tremors 

• from 9 years ago 
• decreases on alcohol in take. 

8. Altered sleep cycle

PAST HISTORY 

History of TB 10 years ago( used medication for 6 months ?)

not a known case of HTN, DM,CAD,CVD, thyroid disorders epilepsy

No history of surgeries

PERSONAL HISTORY :

1. Diet: mixed
2. Appetite: increased
3. Bowel habits: normal
4. Bladder habits: normal
5. Sleep: inadequate
6. Addictions: alcohol - regular 180ml daily 

FAMILY HISTORY :

Not significant 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

• Pallor          - absent
• Icterus        - absent
• Clubbing    -absent
• Lymphadenopathy    - absent
• Cyanosis     - absent
• Pedal edema  -absent

VITALS :

• Temperature - 100.2F
• Pulse : 94 bpm 
• Respiratory rate : 28 per minute 
• Bp 110/80
• Spo2 99%
• GRBS 109 mg%

CVS EXAMINATION 

 S1 S2 heard

no murmurs

RESPIRATORY SYSTEM

Bilateral air entrty present

NVBS

PER ABDOMEN 

soft, non tender

CNS EXAMINATION :

APRAXIA CHARTING

INVESTIGATIONS

PROVISIONAL DIAGNOSIS

Alcohol withdrawal seizures 

With wet Beti beri ?

With essential tremor? 

With c/o pneu kochis 

TREATMENT GIVEN 

1. INJ THIAMINE 400mg /n 100ml NS/IV/STAT

2. IUF - 0.9 / NS @ 50ml/hr 

3. INJ LORAX 2mg/IV/SOS

4. Tab PROPANOLOL 10mg/ PO/ OD