55 YR OLD MALE WITH TINGLING AND NUMBNESS OF ALL LIMBS AND ALTERED SENSORIUM

202329331 kotaiah
CASE HISTORY AND CLINICAL FINDINGS
PT WAS REFERRED FROM ANOTHER HOSPITAL I/V/O HYPOTENSION
BINGE ALCOHOL DRINKING SINCE 10 DAYS
DEVELOPED TINGLING, NUMBNESS OF ALL LIMBS ON 2/7/23 AND ALTERED SENSORIUM ON
3/7/23 AND WAS TAKEN TO LOCAL HOSPITAL. DUE TO GRBS BEING 40MG/DL,
HYPOGLYCEMIA CORRECTION WAS DONE. BP WAS ALSO NOT RECORDABLE SO
IONOTROPES WERE STARTED AND HE WAS REFERRED FOR FURTHER MANAGEMENT.
NOT A K/C/O HTN, DM, CAD,CVA,EPILEPSY,THYROID DISORDERS ,TB,ASTHMA

DIET : MIXED
APPETITE : NORMAL
BOWEL AND BLADDER : REGULAR
ADDICTIONS : ALCOHOL. LAST BINGE ON 30/6/23. SMOKING
SLEEP: ADEQUATE
ON EXAMINATION
PT IS CONCSIOUS, COHERENT, COOPERATIVE
ORIENTED TO TIME, PLACE, PERSON
B/L PUPIL: NSRL
PALLOR ABSENT
NO ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,OEDEMA
VITALS
TEMP : AFEBRILE
PR : 106 BPM
RR: 16 CPM
BP : NOT RECORDBLE ---> NORAD @6ML/HR---> SBP 60MMHG ---> 2 NS: BP 120/70MMHG
SYSTEMIC EXAMINATION
CVS : S1,S2 HEARD ,NO MURMURS
RS: BLAE PRESENT, NVBS
P/A : SOFT,NON TENDER
CNS: NO FOCAL DEFICITS. E4V5M6
PSYCHIATRY REFERRAL WAS DONE ON 4/7/2023 I/V/O ALCOHOL WITHDRAWAL SYNDROME:
ADVISED TAB OLANZEPINE 2.5MG PO BD
REVIEW REFERRALS DONE DAILY BY PSCHIATRIST
INJ LORAZEPAM IM BD
TAB OLANZEPINE 2.5MG PO BD
INVESTIGATION
HEMOGRAM (4/7/23):
HB: 9.9GM%
TLC: 9300 CELLS/CUMM
PLT: 1.6 LAKH/CUMM
BLOOD GROUP ; B POSITIVE
CUE
ALBUMIN 2+
SUGARS 4+
PUS CELLS : 4 TO 5
 RBS : 136 MG/DL
SERUM AMYLASE ; 116 IU/L
LFT :
T.B : 1.14
D.B : 0.50
SGOT : 86
SGPT : 51
ALP : 69
TP : 5.1
ALBUMIN : 3.26
A/G RATIO : 1.77
BLOOD UREA : 69 MG/DL
SERUM CREATININE : 1.4 MG/DL
SERUM ELECTROLYTES
SODIUM/POTASSIUM/CHLORIDE/CALCIUM IONIZED : 141/3/98/1.06
BLOOD LACTATE - 7.0 MG/DL
HEMOGRAM (5/7/23):
HB: 9.8GM%
TLC: 5500 CELLS/CUMM
PLT: 1.55 LAKH/CUMM
SERUM LIPASE : 64 IU/L
SERUM ELECTROLYTESNa/K /Cl /Ca ; 137/3.2/102/1.17
HEMOGRAM (6/7/23):
HB: 9.5GM%
TLC: 4000 CELLS/CUMM
PLT: 1.64 LAKH/CUMM
BLOOD UREA : 58 MG/DL
SERUM CREATININE : 1.3 MG/DL
SERUM ELECTROLYTES ;
Na /K/CL/Ca : 142/3.2/105/1.17
SPOT URINARY PROTEINS - 4.0
 CREATININE - 214
 RATIO - 0.01
HEMOGRAM (7/7/23):
HB: 9.5GM%
TLC: 4000 CELLS/CUMM
PLT: 1.8 LAKH/CUMM
BLOOD UREA - 42 MG/DL
SERUM CREATININE : 1.0 MG/DL
SERUM ELECTROLYTES :
SODIUM/POTASSIUM/CHLORIDE /CALCIUM IONIZED ; 142/ 3/101/ 1.13
HEMOGRAM (8/7/23):
HB: 9.5GM%
TLC: 5300 CELLS/CUMM
PLT: 2.38 LAKH/CUMM
2D ECHO (5/7/23: BEDSIDE): NO RWMA. MILD LVH.
MODERATE TR WITH PAH, MILD AR, NO MR.
SCLEROTIC AV. NO AS/MS. IAS INTACT
EF- 62%. RVSP 58MMHG. GOOD LV SYSTOLIC FUNCTION.
DIASTOLIC DYSFUNCTION, NO PE.
IVC SIZE 1.56CM MILD DILATED NON COLLAPSING
MILD DILATED RA/RV
24HRS URINARY PROTEIN: 40MG/DAY
24HRS URINARY CREATININE: 1.7G/DAY
24HRS URINARY PRCR RATIO: 0.02
24 HOURS URINE VOLUME: 900ML
URINE C/S: NO GROWTH
BLOOD C/S: NO GROWTH AFTER 24 HOURS OF AEROBIC INCUBATION
DIAGNOSIS
UROSEPSIS WITH DISTRIBUTIVE SHOCK[RESOLVED]
WITH ACUTE KIDNEY INJURY (PRERENAL)[RESOLVED] WITH CHRONIC LIVER DISEASE WITH
HYPOKALEMIA[RESOLVED]
K/C/O ALCOHOL WITHDRAWAL SYNDROME WITH DRY BERI BERI[RESOLVED]
TREATMENT GIVEN
IV FLUIDS NS, RL @75ML/HR
INJ NORAD D5 ACCORDING TO MAP
INJ MAGNEX FORTE IV BD
INJ METROGYL 500MG IV TID
INJ PANTOP IV OD BBF
INJ THIAMINE 200MG IN 500ML NS IV BD
INJ ZOFER 4MG IV OD
INJ LORAZEPAM 2MG IV BD
SYP POTCHLOR 15ML IN ONE GLASS WATER IV TID
TAB OLANZEPINE 2.5MG PO BD
TAB CLINIDIPINE 10MG PO OD
TAB CHLORDIAZEPOXIDE 25MG PO BD
TAB PCM 650MG PO SOS
OINT. THROMBOPHOBE L/A
ADVICE AT DISCHARGE
1.TAB. PANTOP 40MG IV/OD BEFORE BREAKFAST [7AM-X-X] FOR 5 DAYS
2.TAB.THIAMINE 100 MG PO/BD [1-X-1]
3.TAB.CLINIDIPINE 10MG PO/OD
COMPLETE ABSTINENCE FROM ALCOHOL
4. TAB.LORAZEPAM 2 MG
 1-X-2 FOR 2 DAYS
 X-X-2 FOR 2DAYS
 X-X-1 FOR 1 DAY
5. TAB.BACLOFEN 2 MG [1-X-1] FOR 5DAYS
 X-X-1 FOR NEXT 5 DAYS

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