1801006020 - Long case

24 yrs old male came to the medicine OPD with cheif complaint of unstable gait and tremors since 10 days 

HISTORY OF PRESENT ILLNESSES 


Patient was apparently asymptomatic 12 years ago he started drinking alcohol after his mother passed away in a tragic accident , to alleviate that stress. 

He started taking alcohol in the form of ARRACK drinking every alternative day about 1-2 glasses a day

Over the next few months his consumption gradually increased to 3 glasses a  day further to 6 glasses a day.This continued upto 5 years after he started drinking . 

Around 5 years later he shifted to WHISKY  due to ARRACK being banned by the government.He drink around 2 units of whisky daily before going to work and upon returning in the evening he used to feel tired thus used to drink again.

In a few months time his drinking increased upto 12 units a day .

patient also started chewing tobacco since the last 9 years , around 1 packet every 2-3 days

He also complains of sleep disturbances,decreased appetite and sweating if he does not consume alcohol . 

Patient has visual hallucinations , pins and needle sensations 

His family then enrolled him in a deaddiction programme 


no history of any psychiatric conditions .

no history of any head injury .

no history of any loss of consciousness.

no history of any epilepsy.

no fever , vomitings , neck stiffness  

DAILY ROUTINE


patient wakes up at 5 in the morning and freshens up and does all his household chores then has a small glass of alcohol following which he goes to work as a an auto driver , he returns home at around 2 to have lunch and takes another 1-2 glasses of alcohol and goes back to work then he comes back home to have dinner at about 9 and sleeps thereafter


patients family members claim that he sneaks out at night to consume more alchol and gets into physical altercation with his family frequently when confronted



PAST HISTORY:  

Not a known case of hypertension, diabetes mellitus , epilepsy, asthma ,tb , cad , cvd , thyroid 

Patient has a history of fracture to the left arm following an accident, it is fixed with a DCP plate . 

PERSONAL HISTORY : 

Appetite - normal   .

Diet - mixed , inadequacy in nutrition. 

Sleep - disturbed .

Bowel and bladder movement- regular.

Addictions : alcohol consumption since the age of 11 years .

 chewing of gutka since the age of 11 years . 

Allergies : No allergies . 


GENERAL EXAMINATION: 

Patient was examined after taking consent in a well lit room . 

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

Poorly Built and poorly Nourished .


Temp: Afebrile 

BP : 130 / 90 mmHg 

PR : 87bpm 

RR : 18 cpm  


Pallor : absent 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Generalized Lymphadenopathy : absent 

Bilateral pedal Edema : absent   











SYSTEMIC EXAMINATION: 


CNS :  

Higher mental functions 

Conscious , oriented to person , place and time .

Speech : slightly slurred 

Memory: intact 

Visual hallucinations present 

No delusions 

No emotional liability 

MMSE score - 27/30

CRANIAL NERVE EXAMINATION:


1st   : Normal


2nd  :  visual acuity is normal


                  

3rd,4th,6th  :  restricted ocular movements .

                           pupillary reflexes present.

                          Nystagmus - present .  


5th             :  sensory intact


                      motor intact


7th             :  normal


8th             :  No abnormality noted.


9th,10th     : palatal movements present and equal. 


11 th : intact 

12 th : normal 


Motar examination 


              RT                               LT 

             UL      LL               UL    LL

Bulk : Normal Normal Normal Normally 

Tone : Normal Normal Normal Normally

Power : 5/5   5/5                5/5    5/5


Reflexes :   biceps: present   present present 

 

                    Triceps : present   present present    


                   Knee: present   present present present    


                   Ankle : present   present present present    



           


SENSORY EXAMINATION:  


SPINOTHALAMIC SENSATION:


Crude touch : Normal


pain : Normal 


temperature : Normal 


DORSAL COLUMN SENSATION:


Fine touch : normal 


Vibration : normal 


Proprioception : normal 


Rombergs sign : negative  


https://youtube.com/shorts/Y6CGqh_wrII?feature=share


CORTICAL SENSATION:


Two point discrimination : normal 


Tactile localisation :  normal 


CEREBELLAR EXAMINATION:

 Slight tremors are present 

Truncal ataxia - present 

Gait ataxia - present 

Nystagmus- present 


https://youtu.be/8U4NCKl60-w


Coordination -   Finger nose test   - slightly altered 



                                    Heel knee test  - slightly altered 

                                    




                             



  Dysdiadochokinesia    - absent 


                                          https://youtube.com/shorts/LUSDgPWYsSo?feature=share


GAIT:      https://youtube.com/shorts/x0k9rWWj06I?feature=share


wide based gait, swaying to sides , 

Unsteady with a tendency to fall. 


unable to perform tandem walking. 



SIGNS OF MENINGEAL IRRITATION: 

Neck stiffness - absent 

Kernigs sign - absent 

Brudzinskis sign - absent 


 CVS

Apex at normal position 

S1 S2 + ,no murmurs 


Respiratory system

chest shape normal 

Trachea central 

Bilateral air entry Present 

Non vesicular breath sounds present 


P/A : Soft and Non tender 

          No organomegaly 


Investigations   


Hemogram 

Hb - 12 gm/dl ( normal =13-17 ) 

Total count - 10,200 ( normal 4000 - 10000) 

Lymphocytes- 18 ( normal 20-40) 

            Pcv     - 37.7 ( normal 40 - 50) 

     RBC count-3.89 million ( normal 4.5 - 5.5 )  




Liver function tests 

Total bilirubin- 1.32 mg/dl ( normal 0-1) 

Direct bilirubin- 0.34 ( normal 0 - 0.2 ) 

Alkaline phosphate -185IU/L ( normal 53 - 128 ) 


Renal function test 

Creatinine- 1.4 mg/ dl ( normal 0.9 - 1.3 ) 


Echo

Normal size liver with increased ecogenicity and partially distended gallbladder  


Chest x ray: 


ECG : 




Provisional diagnosis 

1. Wernickes encephalopathy  ( vit b1 deficiency)

2. Cerebellar degeneration secondary to alcohol consumption 

3. Alcohol withdrawal delirium 


Treatment 

1. Tab lorazepam 2mg 

2. Tab benfothiamine 100mg bd 

3. Tab baclofen 20mg od 

4. Nicotine gums 2 mg 

5. Counselling 



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