Elog: 14 may 2020 elog

14 may 2020 elog medicine intern

Hello everyone... I am an intern in medicine department and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties.

CASE:

A 27 year old male patient presented with chief complaint of vomiting since 2 days, with decreased in take of food since 4days.

Patient was apparently asymptomatic 4 days back, then he had decreased in take of food since 4 days following alcohol intake(local toddy). Then he has H/O vomiting since 2 days which is non bilious, non blood stained not a/w pain abdomen, loose stools.

H/O seizures 2 days back after stopping alocohol, no H/O frothing, loc, uprolling of eyes,

involuntary bowel and bladder movements.

H/O decreased responsiveness for which he was admitted in local hospital and treated as DELIRIUM TREMERS.

PAST HISTORY:

K/C/O chronic alcoholic since 4 years(90-180ml whiskey per day)

H/O beetle chewer

H/O similar episodes

Not a K/C/O DM/HTN/EPILEPSY/CVA/CAD.

PERSONAL HISTORY:

Mixed diet with normal appetite, regular bowel and bladder movements.

h/o alcohol intake.

No drug and allergic history.

No significant family history.

GENERAL EXAMINATION:

Patient was conscious,coherant,cooperative

Moderately built and nourished

No signs of pallor,icterus,cyanosis,clubbing, lymphadenopathy,edema.

Vitals:

Temperature:A febrile

Pulse rate :92/ min

Respiratory rate:18/min

BP :110/90 mmhg

Spo2 :96%

GRBS :91mg

SYSTAMIC EXAMINATION:

CVS:s1, s2 hered, no murmurs

RS:bae +, nvbs hered

P/A:soft, non tender

CNS:HMF normal, patient oriented to place/time/person

Cranial nerves intact

Motor and sensor system normal

No meningeal signs and cerebellar signs

Based on these findings,he was diagnosed with -

Alcohol induced gastritis with K/C/O delirium tremens and alcohol dependent syndrome

Advise:psychiatry referral

Rx:1.Inj.pantop 40mg/iv/od

2.Inj.zofer 4mg/iv/bd

3.Inj.thiamine iv/td

4.Inj.optineuron 1amp in 100ml/iv/od

5.Ivf-NS, RL, DNS

6.T.clonazepam 0.25mg

Dept of psychiatry

C/O abnormal behaviour since 3 to 4 days characterised by starry looks, episodic irritability, sleeplessness, increased reaction time to the question asked.Started with pain in neck with involuntary movements of head followed by above symptoms taken to outside local hospital treated for hypokalemia.

Substance use history-alcohol intake history mentioned above

Similar episodes were reported 14 days back and 1 year back

O/E conscious oriented sat on chair has starry look etec maintained raport established speech normal, reaction time increased, relevant, coherant

As per history given by patient

DD:1.Prodromal psychosis

2.Alcohol induced psychosis

Rx:1.T.Oleanz 5mg

2.T.Enchorate Chrond 300mg

3.T.Diazepam 5mg