ALTERED SENSORIUM SECONDARY TO ALCHOHOL WITHDRAWL

Case History and Clinical Findings 
PATIENT WAS BROUGHT TO THE CASUALTY INSTATE OF SUDDEN ONSET OF ALTERED SENSORIUM SINCE 5AM ON 24-01-23 HOPI : PATIENT WAS APPARENTLY ALRIGHT UNTILL 5AM ON 24-01-23 , HE WOKE UP THEN AND WENT TO OPEN THE DOOR AND HE LEANED ON TOTHE DOORAND DIDNOT OPEN THE DOOR. HE THEN PASSED URINE INVOLUNTARILY AND SINCE THEN HE IS NOT RECOGNISING HIS FAMILY MEMBERS .HE IS AGITATED WITH MOVING ALL UPPER AND LOWER LIMBS AND PT IS IN CONFUSED STATE WITH GCS E2V2M4 - E4V4M4-E4V5M6. NO NECK STIFFNESSNO H/O LOSS OF CONSCIOUSNESS/VOMITINGS/DEVIATION OF MOUTH/NO UPROLLING OF EYEBALLS/NO TONIC OR CLONIC SEIZURES/ TRAUMA/FEVER
PAST HISTORY-:
 PATIENT IS A KNOWN CASE OF DIABETES MELLITUS TYPE 2 USING T METFORMIN 500 MG PO /OD ( ON REGULAR MEDICATION ) AND HYPERTENSION SINCE 9 YEARS (FOR HYPERTENSION PATIENT'S ATTENDANT DOESNT KNOW) PATIENT HAD CEREBRO VASCULAR ACCIDENT 9 YEARS BACK WITH LEFT HEMIPERESIS AND PATIENT RECOVERED NOW WITH MILD WEAKNESS OF LEFT UPPER AND LOWER LIMBS. NOT A K/C/O ASTHMA/EPILEPSY/TUBERCULOSIS/CAD/THYROID DISORDERS PERSONAL HISTORY: DIET MIXED SLEEP NORMAL APPETITE NORMAL BOWEL CONSTIPATION+ BLADDER NORMAL ADDICTIONS ALCOHOLIC SINCE 16YEARS ,LAST BINGE ON NIGHT BEFORE ADMISSION AND NON SMOKER NO SIGNIFICANT FAMILY HISTORY O/E PATIENT ON ADMISSION IS IN ALTERED SENSORIUM GCS E2V2M4 TEMP 99.4F PR 108BPM RR 22CPM BP 190/110 MM HG SPO2 97% AT ROOM AIR GRBS 365MG/DL CVS S1 S2 HEARD NO MURMURS RS BILATERAL AIR ENTRY+ NORMAL VESICULAR BREATH SOUNDS+ P/A SOFT NON TENDER BOWEL SOUNDS+ CNS : PATIENT IS IRRITABLE AND AGITATED INAPPROPRIATE SPEECH SIGNS OF MENINGEAL IRRITATION CANNOT BE ELICITED MOTOR SYSTEM INCREASED TONE IN BOTH UPPER AND LOWER LIMBS POWER COULDNT BE ELICITED BUT MOVING ALL LIMBREFLEXES BICEP TRI SUP KNE ANK PLA RT ++ ++ ++ ++ + F LT ++ ++ ++ ++ + F CEREBELLAR SIGNS : CANNOT BE ELICITED SENSORY EXAMINATION (BILATERALLY) SPINOTHALAMIC TRACT 1. CRUDE TOUCH - PRESENT 2.PAIN - PRESENT 3. TEMPERATURE - PRESENT POSTERIOR COLUMN 1.FINE TOUCH - PRESENT 2.VIBRATION (RIGHT AND LEFT) UPPERLIMB - 10SECONDS 10SECONDS UPPERLIMB SUPINATOR - 9SEC 9SEC LOWERLIMB TIBIA - 7SEC 8SEC LOWERLIMB MEDIAL MALLEOLUS - 6SEC 6SEC 3.JOINT POSITION - NOT ABLE TO TELL NOT ABLE TO TELL CORTICAL TRACT 1. GRAPHESTHESIA - PRESENT 2. STEROGNOSIS - PRESENT 3.TACTILE LOCALISATION - PRESENT O/E ON DISCHARGE PT IS ORIENTED TO TIME ,PLACE ,PERSON TEMP 99.4F PR 88BPM RR 18CPM BP 130/80 MM HG SPO2 97% AT ROOM AIR GRBS 152MG/DL CVS S1 S2 HEARD NO MURMURS RS BILATERAL AIR ENTRY+ NORMAL VESICULAR BREATH SOUNDS+ P/A SOFT NON TENDER BOWEL SOUNDS+ CNS : 
 MOTOR SYSTEM NORMAL 
TONE IN BOTH UPPER AND LOWER LIMBSPOWER R L UL 5/5 5/5 LL 5/5 5/5 REFLEXES BICEP TRI SUP KNE ANK PLA RT ++ ++ ++ ++ + F LT ++ ++ ++ ++ + F NO CEREBELLAR SIGNS FINGER TO FINGER TEST FINGER NOSE TEST RHOMBERG TEST STRAIGHT LEG WALKING TEST HEEL KNEE TEST COURSE IN THE HOSPITAL : ON DAY 1 A 65 YEAR OLD MALE WAS BROUGHT TO THE CASUALTY IN ALTERED SENSORIUM SINCE MORNING MRI BRAIN WAS DONE SHOWED HYPODENSE AREA SEEN IN RT SUPERIOR FRONTAL GYRUS AND RT PUTAMEN SUB ACUTE /OLD INFARCT , FEW HYPODENSE AREAS IN BILATERAL PERIVENTRICULAR WHITE MATTER SUGGESTIVE OF SMALL VESSEL ISCHEMIC DISEASE .AND RYLES TUBE WAS PLACED AND HE WAS MANAGED CONSERVATIVELY AND AS HE WAS HYPERTENSIVE SINCE 9 YRS AND DIABETIS MELLITUS TYPE 2 SINCE 9 YEARS AND INJ HUMAN ACTRAPID INSULIN WAS GIVEN @ 8AM 2 PM - 8 PM ACCORDING TO SLIDING SCALE AND ALL ROUTINE INVESTIGATIONS WERE SENT. DAY 2 PATIENT WAS IN ALTERED STATE BUT LESS AGITATED THAN YESTERDAY 2DECHO WAS DONE WHICH SHOWED CONCENTRIC LVH(1.48CMS) LV COLLAPSING NO RWMA MILD TR+ TRIVIAL AR+ NO MR SCLEROTIC AV NO AS/MS IAS INTACT EF 58% GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION NO PE IVC SIZE 1.09CMSIN VIEW OF ALCOHOL DEPENDENCE A PSYCHIATRY OPINION WAS TAKEN AND THEY ADVISED INJ LORAZEPAM SOS IF PATIENT IS MORE AGITATED. DAY 3 PATIENT WAS NORMAL TODAY ANDHE WAS WELL ORIENTED TO TIME PLACE AND PERSON AND NO COMPLAINTS. DAY 4 PATIENT'S ORIENTATION IMPROVED AND HE WAS SHIFTED TO WARD AND PSYCHIATRY REVIEW WAS DONE AND WAS ADVICED FOR TAB.LORAZEPAM SOS IF PATIENT IS AGITATED OR SLEEPLESS. PATIENT SLEPT WELL AND COMPLAINED OF SWAYING BUT CEREBELLAR SIGNS WERE NARMAL AND HE WAS TAKING ORALLY DAY 5 PATIENT GAVE NO COMPLAINTS AND WITH STABLE VITALS HE WAS DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION. Investigation
 MRI BRAIN : 
1.NO ACUTE INTRACRANIAL BLEEDS 2.HYPODENSE AREA SEEN INN RIGHT SUPERIOR FRONTAL GYRUS AND RIGHT PUTAMEN SUBACUTE/OLD INFARCT 3.FEW HYPODENSE AREAS IN BILATERAL PERIVENTRICULAR WHITE MATTER SUGGESTIVE OF SMALL VESSEL ISCHEMIC DISEASE 2D ECHO : CONCENTRIC LVH(1.48CMS) LV COLLAPSING NO RWMA MILD TR+ TRIVIAL AR+ NO MR SCLEROTIC AV NO AS/MS IAS INTACT EF 58% GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION NO PE IVC SIZE 1.09CMS USG ABDOMEN: NO SONOLOGICAL ABNORMALITY DETECTED ECG : NORMAL SINUS RHYTHM 
Diagnosis 1. ALTERED SENSORIUM (RESOLVED) SECONDARY TO ALCOHOL WITHDRAWL 2. K/C/O HYPERTENSION (SINCE 9 YEARS) 3. K/C/O TYPE II DIABETES MELLITUS( SINCE 9 YEARS) 4.H/O CEREBRO VASCULAR ACCIDENT 9 YEARS BACK WITH LEFT HEMIPARESIS SECONDARY TO CHRONIC INFARCT IN RIGHT PUTAMEN AND FRONTAL GYRUS 
Treatment Given
1. IV FLUIDS NS@50ML/HR
 2. RT FEEDS 100ML MILK 4TH HRLY AND 50ML WATER 2ND HRLY 
3. TAB ECOSPIRIN AV (75/10) RT/OD(9PM) 4. INJ HUMAN ACTRAPID INSULIN S/C ACCORDING TO SLIDING SCALE
5. INJ THIAMINE 200MG/IV/TID
6. INJ LORAZEPAM 2 MG HALF AMPULE/IM/SOS
 7. TAB TELMA 40MG/RT/OD AT 8AM 
8. GRBS 6TH HRLY
 9. BP MONITORING HRLY
 10. I/O CHARTING 
Advice at Discharge
 1. PLENTY OF ORAL FLUIDS 
2. TAB GLIMI M1 ONCE DAILY PER ORAL BEFORE BF
 3. TAB THIAMINE 200MG PER ORAL TWICE DAILY AT 8AM AND 8PM FOR 15 DAYS
 4. TAB ECOSPRIN AV75/10MG PER ORAL BED TIME 
5. TAB TELMA 40MG PER ORAL ONCE DAILY AT 8AM
 6. TAB PREGABALIN M 75MG/PER ORAL BED TIME AT 9PM
 7. SYRUP CREMAFFIN PLUS 10ML/PER ORAL BED TIME AT 9PM 
8. PHYSIOTHERAPY DAILY .
 Follow Up
 REVIEW SOS / ON TUESDAY AT GENERAL MEDICINE OPD WITH FBS,PLBS AND PSCHIATRY OPINION FOR DEADDICTION .

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