Thursday, May 14, 2020
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
Class topics:
Learning points
1.Hypertrophic cardiomyopathy
2.Renal tubular acidosis

Have seen pleural tap from left pleural space for CKD on MHD patient(dialysis patient)
NEET TOPIC:
Lung volumes and capacities

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