26-05-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[26-05-2025 16:40] PPM 1: @PPM4 please add the patient's history here
[26-05-2025 16:42] PPM 4: 1. COMPLAINTS AND DURATION
32 year male resident of Pochampally. Bike mechanic by occupation.
Chief complaints: 6 days ago continuous general weakness.
Insidious onset, progressive weakness,
Hematuria 2 episodes - yest night gradually progressive loss of appetite.
No C/o Fever, cough, cold, loose stools, Nausea, vomiting, Burning micturition
No C/o Chest pain, SOB, orthopnea, palpitations
No C/o Visual or Auditory hallucinations
No C/o Trauma
3. HISTORY OF PAST ILLNESS
H/o similar complaints in 2022 H/o Alcohol withdrawal seizure since then Pt is on T LEVIPIL 500mg
Known Hypothyroidism: 6 months
(Non-compliant to drugs)
on Tab Thyronorm 75mcg - 4 days
[26-05-2025 16:44] PPM 1: What about his symptoms related to his sensorium?
[26-05-2025 16:44] PPM 1: Please pm his IP number so that I can collect his EMR summary
[26-05-2025 16:44] PPM 4: Ok sir
[26-05-2025 16:45] PA: Hi sir lavakusha indira
[26-05-2025 16:45] PPM 1: Can you share the patient's history without identifying the patient?
EMR SUMMARY
Age/Gender: 32 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 20/05/2025 04:38 PM
Name of Treating Faculty [AP] (SR) (PGY3) (PGY2) (PGY1) (PGY1)
Diagnosis
WERNICKES ENCEPHALOPATHY ALCOHOL WITHDRAWAL DELIRIUM ALCOHOL DEPENDANCE SYNDROME DENOVO HYPERTENSION
K/C/O HYPOTHYROIDISM SINCE 6 MONTHS
Case History and Clinical Findings
32 year male resident of Pochampally. Bike mechanic by occupation.Chief complaints: 6 days ago continuous general weakness.2. HISTORY OF PRESENT ILLNESS 2 episodes -Insidious onset, progressive weakness, Hematuria yest night gradually progressive loss of appetite. No C/o Fever, cough, cold, loose stools, Nausea, vomiting, Burning micturition No C/o Chest pain, SOB, orthopnea, palpitations No C/o Visual or Auditory hallucinations No C/o Trauma3. HISTORY OF PAST ILLNESS H/o similar complaints in 2022 H/o Alcohol withdrawal seizure since then Pt is on T LEVIPIL 500mg PJ Known Hypothyroidism: 6 month (Non-compliant to drugs) on Tab Thyronorm 75mcg - 4 days
PERSONAL HISTORY: MIXED DIET, APPETITE NORMAL, REGULAR BOWEL MOVEMENTS, MICTURITION NORMAL, NO KNOWN ALERGIES. REGULAR CONSUMPTION OF ALCOHOL SINCE 30 YEARS, SMOKES 3 BIDIS PER DAY. PACK YEARS: 30
FAMILY HISTORY: NOT SIGNIFICANT
GENREAL EXAMINATION: PALLOR AND CLUBBING- PRESENT NO ICTERUS, CYANOSIS, LYMPHADENOPATHY, MALNUTRITION
VITALS: - TEMP: AFEBRILE, BP: 120/70 MMHG, RR: 16CPM, PR: 96 BPM, SPO2: 96% AT RA, GRBS 148 MG%
SYSTEMIC EXAMINATION: - CVS, RS: NORMAL
P/A - SOFT, DIFFUSE TENDERNESS, NO PALPABLE ORGANOMEGALY
CNS: HIGHER MENTAL FUNCTIONS: PATIENT IS CONSCIOUS, ORIENTED TO TIME, SPEECH NORMAL, MEMORY - IMMEDIATE, RECENT, REMOTE NOT INTACT
MMSE 7/30 ORIENTATION-2 REGISTRATION-1
ATTENSION AND CALCULATION-0 RECALL-0
LANGUAGE-4 GCS 15/15 MOTOR
RT LT POWER
U/L 5/5 5/5 L/L 5/5 5/5 TONE
U/L INCREASED L/L DECREASED REFLEXES
RT LT BICEPS +3 +2
TRICEPS +2 +1
SUPINATOR + +1
KNEE +2 +2
ANKLE - +2
PLANTAR EXTENSION EXTENSION CEREBELLAR SIGNS
NYSTAGMUS NOT PRESENT
FINGER NOSE TEST, SINGER FINGER TEST, HEEL KNEE TEST, DYSDIADOKINESIA COULD NOT BE ELLICITED
RHOMBERGS SIGN-POSITIVE MMSE SCORE
21/5/25-7/30
22/5/25-7/30
23/5/25-7/30
24/5/25-28/30
25/5/25-25/30
26/5/25-30/30
PSYCHIATRY REFERRAL WAS DONE I/V/O ALCOHOL WITHDRAWL DELIRIUM AND WAS ADVISED, TAB.LORAZEPAM, TAB.RESPERIDONE, TAB.LIBRIUM
COURSE IN THE HOSPITAL: A 32YR OLD MALE CAME WITH COMPLAINTS OF GENERALISED WEAKNESS SINCE 6 DAYS, ABSTINENCE FROM ALCOHOL SINCE 6DAYS PRESENTING WITH VITALS: TEMP: AFEBRILE, BP: 120/70 MMHG, RR: 16CPM, PR: 96 BPM, SPO2: 96% AT RA, GRBS 148 MG%, AND MMSE SCORE 7/30 AND THE NECESSARY INVESTIGATIONS WERE DONE AND PATIENT WAS DIAGNOSED AS, WERNICKES ENCEPHALOPATHY, ALCOHOL WITHDRAWAL DELIRIUM, ALCOHOL DEPENDANCE SYNDROME AND WAS STARTED ON VITAMIN B1 1GM STAT DOSE AND 400MG PO/TID AND PYSCHIATRY REFERRAL WAS DONE I/V/O ALCOHOL WITHDRAWL DELIRIUM AND WAS ADVISED, TAB.LORAZEPAM, TAB.RESPERIDONE, TAB.LIBRIUM AND ON DAY 3 HE STARTED PRESENTING WITH RAISED BLOOD PRESSURE, SERIAL BLOOD PRESSURE MONITORING WAS DONE AND 2D ECHO WAS DONE AND PATIENT WAS STARED ON CALCIUM CHANNEL BLOCKERS AND ACE INHIBITORS. PATIENT SYMPTOMS IMPROVED AND BP READINGS WERE UNDER CONTROL. PATIENT IS HEMODYNAMICALLY STABLE AND IS BEING DISCHARGED.
Investigation
COMPLETE URINE EXAMINATION: COLOUR Pale yellow, APPEARANCE Clear, REACTION Acidic, SP.GRAVITY 1.010, ALBUMIN +, SUGAR, BILE SALTS AND BILE PIGMENTS Nil, PUS CELLS 2-4, EPITHELIAL CELLS 2-3, RED BLOOD CELLS 3-4, CRYSTALS, CASTS AND AMORPHOUS DEPOSITS Absent
LIVER FUNCTION TEST: Total Bilurubin 1.30 mg/dl, Direct Bilurubin 0.20 mg/dl, SGOT(AST) 51 IU/L, SGPT(ALT) 36 IU/L, ALKALINE PHOSPHATASE 124 IU/L, TOTAL PROTEINS 7.0 gm/dl, ALBUMIN 4.3 gm/dl, A/G RATIO 1.63
THYROID PROFILE: T3 0.84 ng/ml, T4 9.69 micro g/dl, TSH 16.84 micro Iu/ml
RFT: SERUM CREATININE 1.1 mg/dl, BLOOD UREA 19 mg/dl, SERUM ELECTROLYTES- SODIUM 139 mmol/L, POTASSIUM 3.4 mmol/L, CHLORIDE 105 mmol/L
HEMOGRAM: HAEMOGLOBIN 15.6 gm/dl, TOTAL COUNT 5,300 cells/cumm, NEUTROPHILS 45%, LYMPHOCYTES 42 %, EOSINOPHILS 03 %, MONOCYTES 10 %, BASOPHILS 00 %, PCV
40.7 vol %, M C V 83.1 fl, M C H 31.8 pg, M C H C 38.3 %, RDW-CV 11.9 %, RDW-SD 36.1 fl,
RBC COUNT 4.90 millions/cumm, PLATELET COUNT 2.21 lakhs/cu.mm SMEAR: RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute, No hemoparasites seen, IMPRESSION Normocytic normochromic blood picture
SERUM CHLORIDE 101 mmol/L, Sodium 136 mmol/L RBS 114 mg/dl.
2D ECHO: IVC SIZE 0.9CMS COLLAPSING, MILD AR, TRIVIAL TR, NO PAH, NO MR/PR, NO RWMA, NO AS/MS, MILD LVH, GOOD LV SYSTOLIC FUNCTION, GRADE I DIASTOLIC DYSFUNCTION, NO PE, NO LVC.
Treatment Given (Enter only Generic Name)
INJ.THIAMINE IGM IV/STAT INJ.THIAMINE 400MG IV/TID FOR 5 DAYS
TAB.CINOD 10MG+TELMISARTIN 40MG PO/OD TAB.LEVIPIL 500MG PO/OD 1/2-0-1/2 TAB.THYRONORM 75 MG PO/OD 1-0-0
TAB.RESPERIDONE 1MG 0-0-1
TAB.LIBRIUM 25MG 1-1-2
Advice at Discharge
TAB.CINOD 10MG+TELMISARTIN 40MG PO/OD TO BE CONTINUED TAB.THIAMINE 200 MG PO/TID FOR 15 DAYS
TAB.LEVIPIL 500MG PO/OD 1/2-0-1/2 TO BE CONTINUED TAB.THYRONORM 75 MG PO/OD 1-0-0 TO BE CONTINUED
TAB RESPERIDONE 1MG 0-0-1/2 TO BE CONTINUED FOR 4 DAYS TAB.LIBRIUM 25MG X-X-1 PO/HS TO BE CONTINUED FOR 4 DAYS TAB.LIBRIUM 25MG X-X-2 PO/SOS
TAB BACLOFEN 20 MG 0-0-1 FOR 4 DAYS
Follow Up
REVIEW IN THE MEDICINE OPD IN 2 DAYS FOLLOW UP IN 4 DAYS IN PSYCHIATRY OP
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration: - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:26/5/25 Ward: MMW Unit:2
No comments:
Post a Comment