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55 YEAR OLD MALE WITH TINGLING IN ALL LIMBS

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.


Mentioned here are some learning points that I found interesting, both theoretical and practical surrounding this patient:

-Performed multiple Ryle's tube insertions in this patient

-Learnt how to calculate eGFR, and determine type of AKI in this patient


A 55 year old male presented to the casualty with chief complaints of:

Tingling and numbness in all limbs since 3 days

One episode of altered sensorium


History of Presenting Illness:

The patient initially started drinking 15 years ago when he was 40, due to peer pressure as all his friends in farming would drink too. Once his son met with an accident and broke his arm 6 years ago, the patient's drinking increased. 

Started drinking heavily 10 days ago due to his tractor's back getting damaged due to misplacement of goods. He had recently bought that tractor by investing 4 lakhs in it. Unlike previous time, he did not eat much food during his binge episode. 

In the past 10 days, he was drinking alcohol around 100ml per day.

Last drink on 1/4/2023.

Tingling and numbness since the evening around 8pm on 2/7/3023. He kept flailing his arms around and was fidgety.

On 3/7/23 had altered sensorium, was not speaking and was unable to recognise his son and wife. A few hours following this, the attenders took him to a local hospital. He refused to walk to the hospital.

At the local hospital, he was diagnosed with hypoglycemia (GRBS 40mg/dl) and hypotension (BP 50/?) For which he was given pressors and started on 25D. Following this, the doctors apparently asking about the patient's sensorium and it was noted that the patient was oriented to time, place ,person. Over there he was diagnosed with ALI, jaundice, with fever. For two days treatment was given, however, his condition was not improving. The patient attenders did not feel that the treatment was up to the mark in the hospital, hence, two days later, they decided to bring the patient to Narketpally. 


Patient has been smoking since 15 years, 10-20 beedis per day. He started smoking due to peer pressure. 


He came to our hospital on 4/7/2023 with the same complaints. When he came, he already had a Foley's insitu, and a nasogastric tube had already been inserted. 


SUBSTANCE USE,PSYCHOSOCIAL HISTORY:

(ELICITED FROM PATIENT 'S SON WHO LIVES WITH HIM)


He started drinking 20 years ago due to peer pressure,as all his friends were drinking at the time.

For 1 month, he would continuously drink. Then for the next 5 months he would stop. 

The main reason for doing this was because he didn't have enough money to spend on alcohol, so he would save up and spend all at once. 

At the start of the month, he would drink beer. However because beer is costly, he would switch to whiskey after 7-10 days, around 100ml a day. Then towards the end he would drink Sara (alcohol extracted from jaggery) as it is the cheapest out of his options. He would drink about 10-15 satchets per day. 

Between his binge drinking episodes, he would be sober for 5 months. As soon as he stopped drinking, he would have tremors for 3-4 days, but no other symptoms. 


During his binge drinking episodes, he continued his daily routine as per usual. He would even drink and drive. 


During his binge drinking months, earlier the attenders earlier used to provide him with proper food and water, to make sure he was well fed and well rested. However, they would often scold him for drinking so much. They never stopped giving him food and water though, because he was well behaved and was otherwise a good worker and was peaceful at home. So they would bear with him for the one month that he would drink.


The son, however, used to scold him often when he went into this state. The son stated that he was scared of the father's condition, especially because 2-3 relatives of theirs had died from complications due to alcoholism. He also stated that before this the father had no significant health complaints, and felt that the patient had ruined his own health by drinking. 


In the last episode of binge drinking, which started 10 days before first admission, the patient and his wife fought. 

The villagers had intervened, saying that it is the family member's responsibility to control this, and hence the wife scolded him. However, he shouted at his wife, which scared the son as the wife has both HTN and DM and shouldn't take stress. 


So, for 4-5 days, the patient was not fed properly, nor did he ask for food. The attenders thought that maybe they were allowing his behaviour, by feeding him whenever he went into this state, so they stopped this time. He was also rarely drinking water. Following 5 days of this, his symptoms started.


The attender (patient's son) noted that Saida was not the patient's friend (history was noted because the patient kept referring to a person named Saida, saying he has to meet him).

Saida had taken a loan of 30,000 rupees from him and was refusing to return it. Before being admitted, the patient had gone to Saida 's house demanding money a few times.


Patient has also been smoking since 15 years, 10-20 beedis per day. He started smoking due to peer pressure. 



Daily routine:


On days that the patient didn't drink :

He would awake up at 5.30am, breakfast around 9am- rice and some curry. Then he would go for work driving his tractor and would come back by 1pm to have lunch- rice and sambhar. He would go out again, usually for some tractor of field work. Then he would come back by 8pm for dinner.


On the days that he would drink, he would drink outside before coming home for dinner, freshen up and fall asleep. He often drove his tractor while drunk. Otherwise, he followed the same routine. 


The attenders did not note any difference in his demeanor when he drank, he had always been a bit angry by nature and would raise his voice if needed. However, he never hit anyone and would rarely get into fights.


PAST History:

No similar complaints in the past.

He is not a known case of DM, HTN, CVA, CAD, asthma, epilepsy.


GENERAL EXAMINATION: 





Patient is conscious, coherent and co-operative.

Mooderately built and moderately nourished.

Pallor - Absent

Icterus - Absent

Cyanosis - Absent 

Clubbing - Absent 

No lymphadenopathy

Pedal edema- Absent














Vitals : 

Temperature - 100.2 ° F

Blood Pressure -Non recordable

Started NORAD 6ml/hr--->SBP 60mmHg--->with 2 NS BP 120/70mmHg at 6pm.

Pulse Rate -102 bpm

Respiratory Rate - 20 cpm


SYSTEMIC EXAMINATION: 

PER ABDOMINAL EXAMINATION:

INSPECTION-

Shape of abdomen : flat

Umbilicus : inverted 

All quadrants of abdomen move with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 


PALPATION-

Abdomen soft

No local rise of temperature 

No tenderness

Inspectors findings are confirmed 

No organomegaly 


PERCUSSION:

Resonant note heard over all quadrants


AUSCULTATION:

Bowel sounds heard  



CVS EXAMINATION:

INSPECTION

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse not visible


PALPATION:

Apex beat localised 




AUSCULTATION:

S1 and S2 heard

Murmurs heard over tricuspid and pulmonic region



RS EXAMINATION:

INSPECTION: 

Shape of chest: bilaterally symmetrical

Expansion of chest: Equal on both sides

Position of trachea: Central

No visible scars, sinuses, pulsations



PALPATION:

Inspectory findings confirmed

No tenderness, local rise of temperature

Normal expansion of chest on both sides in all areas

Position of trachea: Central

Vocal fremitus: resonant note felt



PERCUSSION:

Resonant note heard over all areas


AUSCULTATION:

BAE positive

Vocal resonance: resonant in all areas


CNS EXAMINATION:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

E4V5M6


CRANIAL NERVES-

Normal


SENSORY EXAMINATION

No fine touch sensations present in soles

Normal sensations felt in all dermatomes


MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait


REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited


EVALUATION:

Hemogram

Hb- 9.9

TLC- 9300

N/L/E/M- 77/13/1/9

PCV- 29.3

MCV- 83.5

MCH- 28.2

MCHC- 33.8

RDW-15.4

RBC-3.51

PLT-1.6


RBS- 136MG/DL


Blood urea- 69

Creatinine- 1.4

Na- 141

K- 3.0

Cl- 98


BGT- B positive


CUE

Albumin ++

Sugars ++++

Pus cells 4-5

Epithelial cells 2-4

RBCs NIL


LFT

TB- 1.14

DB- 0.50

AST- 86

ALT- 51

ALP- 69

TP- 5.1

ALBUMIN- 3.26

A/G- 1.77


Serum Amylase- 116

Serum lipase- 64


Spot urinary proteins- 4.0

spot urinary creatinine- 214

Ratio- 0.01


24 hours urinary protein- 40

24 hours urinary creatinine- 1.7

Ratio- 0.02


Blood C/S: No growth after 24 hours of incubation

Urine C/S: No growth


ECG:



USG:


Impression: Grade II Fatty Liver


CXR:



2D ECHO:




DIAGNOSIS:

DISTRIBUTIVE SHOCK WITH AKI (PRERENAL) WITH CHRONIC LIVER DISEASE WITH HYPOKALEMIA

K/C/O ALCOHOL WITHDRAWAL SYNDROME WITH DRY BERI BERI


UPDATED FEVER PROFILE WITH HEMOGRAM, RFT TRENDS:


Psychiatry referral from Day 1 of admission:






TREATMENT ADVISED:

IV FLUIDS NS, RL @75ML/HR

INJ NORAD D5 ACCORDING TO MAP

INJ MAGNEX FORTE IV BD

INJ PANTOP IV OD BBF

INJ THIAMINE 200MG IN 500ML NS IV BD

INJ ZOFER 4MG IV OD

INJ LORAZEPAM 2MG IV BD

SYP POTCHLOR 15ML IN 1 GLASS WATER IV TID

TAB OLANZEPINE 2.5MG PO BD

TAB CLINIDIPINE 10MG PO OD

TAB CHLORDIAZEPOXIDE 25MG PO OD

TAB PCM 650MG PO SOS

OINT. THROMBOPHOBE L/A


SOAP NOTES

DAY 2, 3:

S

Patient is conscious but irritable oriented to time , place , person . 

Fever spikes +

Stools passed


O

Patient is conscious and confused. oriented to time , place , person . 

Temp: 99.7F 

Bp : 130/90 mmhg 

PR: 85bpm

RR: 28cpm

CVS: s1s2 positive

RS: b/L air entry present,NVBS +

P/A: soft , non tender 

CNS-NFAD


A

UROSEPSIS WITH DISTRIBUTIVE SHOCK (RESOLVED ) WITH ACUTE KIDNEY INJURY (PRE RENAL ) (RESOLVED )WITH CHRONIC LIVER DISEASE 

K/c/o ALCOHOL WITHDRAWAL SYNDROME. WITH DRY BERI BERI?


P

IV fluids , NS , RL 75ml / hr 

Inj PANTOP 40 mg IV /OD /BBF

Inj THIAMINE 200 mg in 500 ml NS IV /BD

Inj ZOFER 4mg IV/OD 

INJ LORAZEPAM 2 mg IM /SOS

Ointment THROMBOPHOBE for L/A 

TAB CLINIDIPINE 10 mg PO/OD

TAB OLANZIPINE 2.5 mg PO/BD

TAB CHLORDIAZEPOXIDE 25mg PO OD

SYP POTKLOR 15 ml in one glass water PO/TID 


DAY 4:

S

Patient is conscious, coherent, cooperative. Oriented to time, place, person 

No fever spikes

Stools passed


O

Patient is conscious, coherent, cooperative. oriented to time, place, person 

Temp: 99.1F 

BP : 140/90 mmhg 

PR: 88bpm

RR: 20cpm

GRBS: 95mg/dl at 8am

CVS: S1, S2 heard

RS: B/L air entry present,NVBS 

P/A: soft , non tender 

CNS-NFAD


A

UROSEPSIS WITH DISTRIBUTIVE SHOCK (RESOLVED ) WITH ACUTE KIDNEY INJURY (PRE RENAL) (RESOLVED )WITH CHRONIC LIVER DISEASE WITH HYPOKALEMIA (RESOLVED)

K/C/O ALCOHOL WITHDRAWAL SYNDROME WITH DRY BERI BERI 


P

IV fluids: NS, RL @ 75ml / hr 

Inj PANTOP 40 mg IV /OD /BBF at 7am

Inj THIAMINE 200 mg in 500 ml NS IV /BD

Inj ZOFER 4mg IV/OD 

INJ LORAZEPAM 4 mg IM /SOS

Ointment THROMBOPHOBE L/A 

TAB CLINIDIPINE 10 mg PO/OD

TAB OLANZIPINE 2.5 mg PO/BD

TAB CHLORDIAZEPOXIDE 25mg PO/BD

INJ PCM 1GM SOS IF TEMP>101



ADVICE AT DISCHARGE:

1. TAB PANTOP 40MG IV OD BEFORE BREAKFAST FOR 5 DAYS

2. TAB THIAMINE 100MG PO BD

3. TAB CLINIDIPINE 10MG PO OD

4. COMPLETE ABSTINENCE FROM ALCOHOL

5. TAB LORAZEPAM 2MG

1-X-2 FOR 2 DAYS

X-X-2 FOR 2 DAYS

X-X-1 FOR 1 DAY

6. TAB BACLOFEN 2MG 

1-X-1 FOR 5 DAYS

X-X-1 FOR 5 DAYS




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