General medicine case 4

45 YEAR OLD PATIENT WITH ALTERED SENSORIUM 

Sep 20,2021

*ICU admission under Unit 6*

"The patient history was taken from the psychiatry notes written by Dr.Raghunath sir,Dr.Somera mam and Dr.Manasa mam".

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CASE:

A 45 year old patient farmer by occupation was presented to the Casualty with chief complaint of altered sensorium since 1 week secondary to hyponatremia?? Alcohol withdrawal??

History of present illness:

Patient was apparently asymptomatic 1 week back before standing illness.Then the patient was admitted to casualty on 18/09/2021 complaining of altered sensorium.

Patient had hyponatremia with history of alcohol withdrawal and seizures with alcohol and tobacco dependence.

According to the patient's wife, patient consumes alcohol 12 units twice a week since 10 years.

1 year back patient had an injury to his back under the influence of alcohol when he was asked to stop alcohol consumption completely because of jaundice.since then patient didn't consume alcohol until 10/09/2021 when he consumed alcohol.Patient had vomitings of 2 to 3 episodes at 2 o'clock that night (according to his wife) and also Chills and febrile for which he was taken to nearer hospital.I.V fluids and medications are given for the same.Symptoms got reduced on taking medications.

 

But it has recurred on 12/09/2021 where he was to nalgonda govt hospital.

On 12/09/2021 night patient threw seizures (Tonic clonic seizures) for the first time, with tongue bite as per patient's wife.Post ictal confusion was present. Since then patient was weak and drowsy after the episode of seizures.As they found patient was not improving he was shifted to some private hospital.There treatment was given treatment for dyselectrolytemia. Patient was improved in 3 -4 days but again started deteriorating from 18/09/202 morning.Patient was advised for imaging and was asked to take patient to higher center, so was admitted to our hospital on 18/09/202 at 4 pm 

Patient had a habit of chewing tobacco once in 3 days.

Patient had sleep disturbances, cravings and tremors if he doesn't consume alcohol and tobacco.

On presentation:

Patient is Thin built and shivering at times.

Patient was lying in fetal position.

Opening eyes on calling his name.

According to history of patient having spikes of fever along with confusion and drowsiness.

Need of ruling out causes for seizures and altered sensorium.

No H/o other substance use.

No H/o head injury.

No H/o self talking,self smiling.

No H/o pervasive low mode suicidality.

No H/o repetitive thoughts and actions.

No H/o blood in vomitus and stool.

No significant H/o psychiatric history in family.

Past history 

No history of DM/HTN/Epilepsy/TB/Thyroid disorders

The patient had not undergone any surgeries.

Personal history 

Diet : mixed

Appetite : normal (according to patient's wife)

Bowel and bladder : normal 

Sleep : disturbances

Addictions: pan since 15 years daily 1 pack and alcohol consumption since 15 years weekly thrice.No history of smoking.

Family history

No history of DM/HTN/CVA/CAD/Asthma/thyroid disorders

No similar complaints in the family previously. 

Treatment history 

Not significant. 

General examination

Patient is conscious but drowsy.

Oriented to person only.

No pallor, history of icterus previously but not now,no cyanosis,no clubbing,no lymphadenopathy. 

Vitals

Bp :110/70 mm hg

PR: 110bpm

Spo2: 98% 

Temperature:101'F

Systemic examination:

CARDIOVASCULAR SYSTEM:

Inspection:

Chest wall is bilaterally symmetrical.

No precordial bulge.

Palpation:

JVP: normal

Auscutation:

Normal with regular heartbeat

S1, S2 heard

No murmurs 

RESPIRATORY SYSTEM-

Position of trachea: central

Normal Bilateral air entry

No AV sounds

PER ABDOMEN:

Normal. No mass is palpable. 

No organomegaly

CENTRAL NERVOUS SYSTEM:

Patient is Conscious but drowsy.

Patient is responding to our speech on repeated asking.

Investigations:

On 18/09/21

Hemogram:

RBC:3.36 millions/cumm

WBC:11,600 cells/cumm

PLATELETS:2.66 lakhs/cumm.

Hb:10.2 gm/dl

CUE:

Albumin-nil

Sugars-nil

Pus cells:2-3

Epithelial cells:2-3

Blood urea:22mg/dl

Serum creatinine:0.7mg/dl

Serum electrolytes:

Na+:130meq/l

K+:4.5meq/dl

Cl-:92meq/dl

Liver function tests:

ALP:184 IU/L

SGOT:157IU/L

SGPT:51U/L

ALBUMIN:3.1 gm/dl

Urinary electrolytes:

Na+:298 mmol/L

K+:12.3

Cl-:381 mmol/L

HbA1c:6.5%

On 19/09/2021

Pt:18 Sec

INR:1.2

Aptt:36 sec

Patient is drowsy.

Temp:99.1'F

BP: 90/6/mmHg

PR:  98

CVS: S1 AND S2 HEARD

CNS: intact

RS: NVBS,BAE+

P/A: Soft and non- tender.

On 20/09/21

Na+:132 meq/l

K+:3.9meq/dl

Cl-:99meq/dl

ALP:184 IU/L

SGOT:157IU/L

SGPT:51U/L

Patient is conscious.

Temp:100'F

BP: 100/70 mmHg

PR: 99

CVS: S1 AND S2 HEARD

CNS: intact

RS:NVBS+

P/A: Soft

Other investigations:

Serum sodium chart of the patient:

TPR CHART:

On palpation of stomach,it's tender indicating there is no organomegaly

ECG:

On 18/09/21

On 19/09/21

Provisional diagnosis:

ENCEPHALOPATHY??

MENINGITIS??

Treatment:

18/09/2021

1.Tab. Lorazepam 2 mg PO SOS

2.Monitor vitals 6th hrly

19/09/2021

1.RT feeds 

       200ml milk with protein powder 2 nd hrly

       100ml with water

2.IV FLUIDS

       0.9% NS @150ml/hr

       RL

3.INJ. PANTOP 40 mg IV/OD

4.INJ.ZOFER 4 mg IV/SOS

5.INJ. THIAMINE 4 mg IV/TID

6.INJ. CEFTRIAXONE 2gm IV/BD

7.INJ. LEVIPIL 50 mg IV/BD

8.BP/PR/TEMP/PR 4th hrly

9.I/O CHARTING

20/09/2021

1.IV FLUIDS

       0.9% NS @150ml/hr

       RL

2.INJ. PANTOP 40 mg IV/OD

3.INJ.ZOFER 4 mg IV/SOS

4.INJ. THIAMINE 4 mg IV/TID

5.INJ. CEFTRIAXONE 2gm IV/BD

6.INJ. LEVIPIL 50 mg IV/BD

7.MONITOR VITALS 4th hrly

8.GRBS 4th hrly

9.I/O AND TEMPERATURE CHARTING

10.INJ. LORAZEPAM 2CC/IV/SOS (if seizures)

1. How is alcohol withdrawal related to altered sensorium??

2.Why does the alcohol withdrawal patient's have hyponatremia??

3.Does the alcohol withdrawal may lead to Shock??

4.What are the other complications of alcohol withdrawal??

5. What are the symptoms of an alcoholic liver disease patient??How can it be treated??