ALTERED SENSORIUM IN 40 Y/O MALE

A 40 Year Old Male with Complaints of Irrelevant Talking

This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.

A 40 year old male presented to the hospital from Yadagirigutta with the chief complaints of irrelevant talking and decreased food intake since 9 days. 

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 9 days ago, when he started talking, as well as laughing to himself, which was sudden in onset. He was conscious, but oriented to time, person and place only from time to time. He was unable to lift himself off the bed and move around, and had to be assisted. It was associated with a decrease in food intake since 9 days. Following this, he was taken to a local RMP, given IV fluids, and referred to a higher care hospital. He had also stopped drinking the same day, citing general body pains the day before.

His last alcohol intake was on Monday, when he had drank around 1 bottle. 

He also had short term memory loss since 9 days, where he could not recognize family members from time to time. 

Previously, he had 2-3 episodes of seizures, one being 1 year ago and the most recent being 4 months ago. The most recent time, (4 months ago), he had developed seizures (most probably GTCS) following cessation of alcohol for 24 hours, which was associated with restlessness, sweating, and tremors. Following this episode, he started drinking again. 

He was admitted to a tertiary care hospital on 15th May.

PAST HISTORY:

-History of 2-3 episodes of seizures in the last year, most likely due to alcohol consumption

-K/C/O Type 2 Diabetes since 2 years, for which he has been irregularly taking tablets (once in 2 or 3 days)

-No similar complaints in the past

No history of hypertension, CAD, TB or asthma

PERSONAL HISTORY:

Diet: Mixed

Appetite: Decreased

Sleep: Disturbed

Bowel and bladder: Regular

Addicted to alcohol, drinks about 3-4 quarters per day- since 12 years

Addicted to cigarettes, smokes around 10 per day

DRUG HISTORY

On oral hypoglycemic for DM2 since two years, tablets being taken irregularly

No known drug allergies

FAMILY HISTORY:

No similar complaints in the family

No H/O psychiatric illness in the family

GENERAL EXAMINATION: (at the time of admission)

The patient was examined in a well lit room, with informed consent.

Conscious and co-operative, but not coherent.

Not oriented to time, person and place.

Speech is normal, but talks about irrelevant things.

Moderately built and well nourished.

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent 

Pupils: Normal in size, reactive to light

Vitals: 

16/05/21                                  17/05/21                                      18/05/21                   19/05/21

HR: 110bpm                          HR: 101bpm                            HR: 110bpm                HR:84bpm

BP: 100/60mmHg                 BP:100/70mmHg                     BP: 110/70mmHg       BP: 150/90mmHg

Temp: Febrile on touch         Temp: One spike at 7am          Temp: Afebrile            Temp: Afebrile

SYSTEMIC EXAMINATION: (at time of admission)

CVS: S1, S2 heard

Respiratory: Bilateral Air Entry positive

Per Abdomen: Soft and non-tender, bowel sounds heard

INVESTIGATIONS:

1. CXR-PA view

2. ECG report

3. CBP

-Hb: 11.1g% (decreased)                                          -MCV: 90.2fl

-WBC: 18,300 cells/cumm                                      -MCH: 32.6pg (increased)

-Platelet count: 1.51 lakh/cumm                              -MCHC: 34.6% (increased)

-PCV: 32.1% (decreased)

-Smear findings: Normocytic normochromic anemia, leukocytosis

4. Urinary Chloride, Sodium, Potassium

      -Chloride: 375 mmol/L

      -Potassium: 16.4 mmol/L

      -Sodium: 244 mmol/L

      -Ketone bodies absent in urine

5. CUE

      -Normal

6. Serum electrolytes

     -K: 2.9 mEq/L (decreased)

     -Cl: 112 mEq/L (increased)

7. LFT

       -Albumin: 3.3g/dL (decreased)

8. RFT

     -Urea: 248mg/dL (increased)

     -Creatinine: 3.8 mg/dL (increased)

     -Uric Acid: 18mg/dL (increased)

       Consistent with prerenal AKI.

9.RBS

     -215mg/dL (increased)

10. ABG

10. 2D ECHO

      -Mild LV hypertrophy

11. USG abdomen

     -Bilateral Grade1 RPD

     -Echogenic intramural foci noted in gallbladder

REFERRAL TO PSYCHIATRY:

-Patient experienced tremors, sleep disturbances, sweating when he does not consume alcohol.

-Patient told wife that he saw his brother (who expired recently) and was talking to him.

-H/O multiple involuntary movements associated with rolling of eyes, frothing, tongue bite, loss of consciousness.

-No H/O suspiciousness, pervasive mood, suicidal ideation, grandiosity, repetitive thoughts.

Examination: 
   -Patient is anxious, lying on the bed. Tremors present. 
   -Conscious, coherent, co-operative. Well oriented to time, place, person.
   -Established rapport, answers questions but talks irrelevant things.
   -Thought and perceptions could not be established.

Inferences:

    -Alcohol Dependence Syndrome with complicated withdrawal state

  

REFERRAL TO SURGERY:

2x2cm chronic ulcer on heel of R foot with sloping edges

Pale granulation tissue present

Surrounding tissues normal

Peripheral pulses present

Sensation near normal

PROVISIONAL DIAGNOSIS:

1. Wernicke's encephalopathy secondary to chronic alcohol dependence.

2. Uraemic encephalopathy.

3. Alcohol Withdrawal delirium.

TREATMENT REGIMEN:

1. IVF NS and RL @150ml/hr

2. Inj. 1amp THIAMINE in 100ml NS, TID

3. Inj. Lorazepam

4. T. Pregabalin 75mg/PO/ BD

5. Inj. HAI S.C.- premeal

6. GRBS 6th hourly, premeal: 8am, 2pm, 8pm,2am

7. Lactulose 30ml/PO/BD

8. Inj 2 ampoule KCl (40mEq) in 10 NS over 4 hours

9. Syp Potchlor 10ml in one glass water/PO/BD

For the ulcer:

1. Daily dressing

2. Megaheal ointment

3. Avoid pressure over ulcer