50 year old female with Dysphagia under evaluation Anemia under evaluation ?ATT induced Steven Johnson ?Plummer Vinson AKI secondary to ?pre renal ?UTI k/c/o DM,HTN, HYPOTHYROIDISM, RHEUMATOID ARTHRITIS

INVOLUNTARY MOVEMENTS OF B/L UPPER AND LOWER LIMBS OF A 38y|M

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

  38 year old male autodriver by occupation came to the casuality with chief complaints of  involuntary movements of both upper and lower limbs 

HISTORY OF PRESENT ILLNESS :- 

patient was apparently normal. Yesterday, after consuming alcohol he started showing aggressive behaviour and developed involuntary movements of both upper and lower limbs- tonic clonic lasted for 10 mins, up rolling of eyes present, tongue bite- present, there was no post icteral confusion or involuntary micturition/defecation.

Visual and auditory hallucinations +/? Fearfulness +/?

No c/o pain abdomen,nausea,vomiting,chest pain, palpitations.

Pt is consuming alcohol since 10-12yrs (180ml/day 3-4 times a week)

PAST HISTORY 

No similar complaints in the past

N/K/C/O. Dm,Htn, Epilepsy

h/o appendicectomy 10 yrs ago

GENERAL EXAMINATION

Patient was conscious, not co operative

pallor , icterus, cyanosis, clubbing, lymphadenopathy,edema are absent 

vitals at the time of admission i.e 28-2-22

temp.  afebrile 

BP 150/100mm hg 

PR 82bpm.

RR 19cpm

spo2 100 @RA 

GRBS 330mg/dl

SYSTEMIC EXAMINATION

Cvs: s1 s2 heard 

RS: BAE +

P/A : soft , non tender 

CNS: Pt is conscious , speech is normal , no signs of meningial irritation

Cranial nerves are intact

Gait is normal

Reflexes : B   T   S   K  A   P

    Rt         +    +   +   +   +   +

    Lt         +     +  +    +   +   +

Power: Rt   Lt

UL       4/5   4/5

LL       4/5    4/5

Sensory system : able to perceive sensations normally 

INVESTIGATIONS

SARS-COV-2 PCR : NEGATIVE 

GRBS: 113mg/dl

BLOOD UREA:

29mg/dl

SERUM CREATININE: 1.5 mg/dl

Serum electrolytes

Na: 136

K: 3.6

Cl: 98

MRI : NAD

EEG:

PROVISIONAL DIAGNOSIS

Seizure under evaluation 

Alcohol withdrawal ?

TREATMENT 

1. Inj LEVIPIL 500mg IV / BD

2. inj OPTINEURON 1amp in 100ml NS IV

3. Inj. THIAMINE 1amp in 100 ml NS IV / TID

4. INJ LORAZEPAM 4mg IV /sos

5.inj pantop 40 mg iv /bd 

6.inj zofer 4 mg iv /sos

1-3-22

Pt is c/c

BP:110/80 mm Hg

PR: 80bpm

CVS: s1 s2 heard

RS: BAE +

GRBS:113mg/dl 

TREATMENT:

1) T. LEVIPIL 500MG

2) INJ. THIAMINE 100MG IV BD

3) ZYTER GEL for L/A on tongue

4) INJ PAN 40MG IV OD

5) INJ ZOFER 4MG IV SOS

2-3-22

Pt is c/c

Vitals are stable

TREATMENT:

1) T. LEVIPIL 500MG

2) INJ. THIAMINE 100MG IV BD

3) ZYTER GEL for L/A on tongue

4) INJ PAN 40MG IV OD

5) INJ ZOFER 4MG IV SOS

6) T.LORAZEPAM 2mg *__*__2

 

7) INJ LORAZEPAM 1/2 amp / 2 mg sos if pt is irritable 

8)NICOTEX GUMS  2mg SOS