WERNICKES ENCEPHALOPATHY WITH ALCOHOL DEPENDENCE SYNDROME ACUTE CVAACUTE LOBAR HEMORRHAGE IN RIGHT FRONTAL LOBE CAUSING MASS EFFECT ON THE VENTRICLES WITH SUBFALCINE HERNIATION TO RIGHT SIDE AND MIDLINE SHIFT OF 10 MM.ACUTE HEMORRHAGE IN RIGHT ANTERIOR TEMPORAL LOBEBOTH THE ABOVE HEMATOMAS ARE SURROUNDED BY EXTENSIVE PERILESIONAL EDEMATHIN LAYER OF SUBDURAL HEMORRHAGE IN RIGHT FRONTAL AND LEFT OCCIPITAL REGIONDIFFUSE CEREBELLAR PALSY

Case History and Clinical Findings 
CHIEF COMPLAINTS; PATIENT WAS BROUGHT WITH CHIEF COMPLAINT OF UNABLE TO STAND AND EAT ON HIS OWN SINCE 20 DAYS URINARY INCONTINENCE SINCE 15 DAYS HISTORY OF PRESENT ILLNESS;
HOPI
 PATIENT WAS APPARENTLY NORMAL 20 DAYS BACK THEN SUDDENLY DEVELOPED INABILITY TO STAND ON HIS OWN AND ALSO INAILITY TO EAT ON HIS OWN GRADUALLY PROGRESSIVE INITIALLY PATIENT USED TO DO HIS OWN ACTIVITIES BUT GRADUALLY STOPPED DOING HIS WORK AND GOT BED RIDDENC/O URINARY INCONTINENCE SINCE 15 DAYS BEFORE THAT PATIENT INFORMED ABOUT HIS URINATION BUT SINCE 15 DAYS HE IS PASSING URINE INVOLOUNTARILY ATTENDERS ALSO COMPLAIN OF PATIENT SELF TALKING AND ALSO PATIENT POINTING ONTO SOMETHING AND TALKING[HALLUCINATIONS-VISUAL] NO H/O FEVER ,SOB,CHEST PAIN,PAIN ABDOMEN SLURRING OF SPEECH SINCE 15 TO 20 DAYS,LAST ALCOHOL BINGE 20 DAYS BACK H/O SIMILAR COMPLAINTS IN THE PAST IN NOV 2022,HE WAS TAKEN TO A LOCAL HOSPITAL 6 TO 7 YEARS BACK STAYED FOR 2 MONTHS AND STARTED CONSUMING ALCOHOL AGAIN 15 DAYS AFTER DISCHARGE PAST HISTORY; N/K/C/O DM2,HTN,TB,EPILEPSY,CVA,CAD,THYROID DISORDERS 
FAMILY HISTORY; INSIGNIFICANT
 GENERAL EXAMINATION; 
PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE WELL ORIENTED TO TIME,PLACE AND PERSON MODERATELY BUILT AND MODERATELY NOURISHED 
NO PALLOR,CYANOSIS,CLUBBING,LYMPHADENOPATHY AND PEDAL OEDEMA 
VITALS;Bp -120/80mmhgPR -72 bpm ;RR : 16cpmSpo2 : 98 on RACNS examination:
SYSTEMIC EXAMINATION:
CENTRAL NERVOUS SYSTEM;
LEVEL OF CONSCIOUSNESS ;CONSCIOUSSPEECH;NORMAL
NO SIGNS OF MENINGEAL IRRITATIONSENSORY SYSTEM
 NORMAL CARDIOVASCULAR SYSTEM:S1 S2 heardNo murmurs.
RESPIRATORY SYSTEM:Dyspnea- NoNo wheezeBreath sounds - vesicularNo Adventitious sounds
ABDOMINAL EXAMINATION:-No tendernessNo palpable liver and spleen.
Bowel sounds - present. 
Investigation
 FBS;138 MG/DL 
T3; HB;12.4 GM/DL
 TC;5,200
 NEUTROPHILS;55% 
LYMPHOCYTES;34% 
EOSINOPHILS;06%
 MONOCYTES;05%
 BASOPHILS;00% 
PCV;38.7 VOL%
MCV 87.6
 MCH;28.1 
MCHC;32.0% 
RBC COUNT:4.4 MILLIONS/CUMM
 PLATELET COUNT;3.2 LAKHS/CUMM IMPRESSION;NORMOCYTIC NORMOCHROMIC BLOOD PICTURE
 USG DONE ON 02/03/2023 IMPRESSION;GRADE I TO II FATTY LIVER
 2D ECHO DONE ON 03/03/2023 IMPRESSION;EF- 64% IVC-0.57CMS[COLLAPSING] MILD AR+,TRIVIAL TR+,NO MR NO RWMA,NO AS/MS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION,NO PAH/PE
Diagnosis
 WERNICKES ENCEPHALOPATHY WITH ALCOHOL DEPENDENCE SYNDROME ACUTE CVAACUTE LOBAR HEMORRHAGE IN RIGHT FRONTAL LOBE CAUSING MASS EFFECT ON THE VENTRICLES WITH SUBFALCINE HERNIATION TO RIGHT SIDE AND MIDLINE SHIFT OF 10 MM.ACUTE HEMORRHAGE IN RIGHT ANTERIOR TEMPORAL LOBEBOTH THE ABOVE HEMATOMAS ARE SURROUNDED BY EXTENSIVE PERILESIONAL EDEMATHIN LAYER OF SUBDURAL HEMORRHAGE IN RIGHT FRONTAL AND LEFT OCCIPITAL REGIONDIFFUSE CEREBELLAR PALSY
PSYCHIATRY REFERRAL TAKEN I/V/O ALCOHOLIC DEPENDENCE SYNDROME. ADVISED;
 1.TAB.CHLORDIAZEPOXIDE 25 MH PO/BD 2.TAB.LORAZEPM 2MG PO/SOS[IF PT IRRITABLE/RESTLESS/AGITATED AND STOP IF PT IS DROWSY]
 2.TO CONTINUE TO THIAMINE SUPPEMENTATION 
3.ADEQUATE HYDRATION 
4. VITALS AND ORIENTATION MONITORING 4TH HOURLY NEURO SURGERY REFERRAL TAKEN I/V/O ACUTE HEMORRHAGE IN BRAIN AND THEIR ADVISE FOLLOWED MRI DONE ON 04/03/2023 ACUTE LOBAR HEMORRHAGE IN RIGHT FRONTAL LOBE CAUSING MASS EFFECT ON THE VENTRICLES WITH SUBFALCINE HERNIATION TO RIGHT SIDE AND MIDLINE SHIFT OF 10 MM.ACUTE HEMORRHAGE IN RIGHT ANTERIOR TEMPORAL LOBEBOTH THE ABOVE HEMATOMAS ARE SURROUNDED BY EXTENSIVE PERILESIONAL EDEMATHIN LAYER OF SUBDURAL HEMORRHAGE IN RIGHT FRONTAL AND LEFT OCCIPITAL REGIONDIFFUSE CEREBELLAR PALSY
 Treatment Given
 1)INJ.THIAMINE 200 ML IN 100 ML NS.I.V/TID
2)INJ.OPTINEURON 1 AMP IN IN 100 ML NS.I.V/TID@8AM,2PM,8PM 
3)I.V FLUIDS 1 NS 1 RL@ 100 ML/HOUR 4)INJ.MANNITOL 100 ML I.V/TID 5)TAB.CHLORDIAZEPOXIDE 250 MG PO/BD 6]TAB.LORAZEPAM 2MG PO/SOS 7]GRBS MONITORING 4TH HOURLY 8]VITALS MONITORING 4 TH HOURLY Advice at Discharge PATIENT IS GETTING DISCHARGED FOR ADMINISTRATIVE PURPOSE TRANSFERRING THE CASE TO NEUROSURGERY DEPARTMENT 
Follow Up
 REVIEW TO MEDICAL OPD AFTER 10 DAYS OR SOS 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. 

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