55 YEAR OLD MALE WITH TINGLING IN ALL LIMBS
A55 year old male presented to the casualty with chief complaints of:
Tingling and numbness in all limbs since 3 days
One episode of altered sensorium
History of Presenting Illness:
The patient initially started drinking 15 years ago when he was 40, due to peer pressure as all his friends in farming would drink too. Initially, he would only drink once every couple of days. However, as the years went on, he started drinking more frequently. Once his son met with an accident and broke his arm 6 years ago, the patient's drinking increased. He would drink around 90ml whiskey daily for months at a time. Then would try to stop altogether, during which time he would develop tremors for the first few days. He would be fully sober for months at a time following which he would start again.
Started drinking heavily 10 days ago due to his tractor's back getting damaged due to misplacement of goods. He had recently bought that tractor by investing 4 lakhs in it. Unlike previous time, he did not eat much food during his binge episode.
In the past 10 days, he was drinking alcohol around 100ml per day.
He would not eat, and was only eating around one meal a day- rice and curry
Last drink on 1/4/2023.
Tingling and numbness since the evening around 8pm on 2/7/3023. He kept flailing his arms around and was fidgety.
On 3/7/23 had altered sensorium, was not speaking and was unable to recognise his son and wife. A few hours following this, the attenders took him to a local hospital at Miryalguda. He refused to walk to the hospital.
At the local hospital, he was diagnosed with hypoglycemia (GRBS 40mg/dl) and hypotension (BP 50/?) For which he was given pressors and started on 25D. Following this, the doctors apparently asking about the patient's sensorium and it was noted that the patient was oriented to time, place ,person. Over there he was diagnosed with ALI, jaundice, with fever. For two days treatment was given, however, his condition was not improving. The patient attenders did not feel that the treatment was up to the mark in the hospital, hence, two days later, they decided to bring the patient to Narketpally.
Patient has been smoking since 15 years, 10-20 beedis per day. He started smoking due to peer pressure.
He came to Narketpally on 4/7/2023 with the same complaints. When he came, he already had a Foley's insitu, and a nasogastric tube had already been inserted.
Daily routine:
On days that the patient didn't drink :
He would awake up at 5.30am, has breakfast around 9am- rice and some curry. Then he would go for work driving tractor and would come back by 1pm to have lunch- rice and sambhar. Then he would come back by 8pm for dinner.
On the days that he would drink, he would drink outside before coming home for dinner, freshen up and fall asleep. He often drove his tractor while drunk.
Psychosocial history:
The patient did not study at all. He currently lives with his wife, son and son-in-law. The patient's attender noted that he gets angry very fast and shouts often, especially when drunk. However, he has never hit any of his family members.
PAST History:
No similar complaints in the past.
He is not a known case of DM, HTN, CVA, CAD, asthma, epilepsy.
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Mooderately built and moderately nourished.
Pallor - Absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
No lymphadenopathy
Pedal edema- Absent
Vitals :
Temperature - 100.2 ° F
Blood Pressure -Non recordable
Started NORAD 6ml/hr--->SBP 60mmHg--->with 2 NS BP 120/70mmHg at 6pm.
Pulse Rate -102 bpm
Respiratory Rate - 20 cpm
SYSTEMIC EXAMINATION:
PER ABDOMINAL EXAMINATION:
INSPECTION-
Shape of abdomen : flat
Umbilicus : inverted
All quadrants of abdomen move with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
PALPATION-
Abdomen soft
No local rise of temperature
No tenderness
Inspectors findings are confirmed
No organomegaly
PERCUSSION:
Resonant note heard over all quadrants
AUSCULTATION:
Bowel sounds heard
CVS EXAMINATION:
INSPECTION
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse not visible
PALPATION:
Apex beat localised
AUSCULTATION:
S1 and S2 heard
Murmurs heard over tricuspid and pulmonic region
RS EXAMINATION:
INSPECTION:
Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
No visible scars, sinuses, pulsations
PALPATION:
Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
BAE positive
Vocal resonance: resonant in all areas
CNS EXAMINATION:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
E4V5M6
CRANIAL NERVES-
Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
PROVISIONAL DIAGNOSIS:
?Hypovolemic shock
?Distributive shock with K/C/O Alcohol Withdrawal Syndrome with Acute Kidney Injury with ?Chronic liver disease
EVALUATION:
Hemogram
Hb- 9.9
TLC- 9300
N/L/E/M- 77/13/1/9
PCV- 29.3
MCV- 83.5
MCH- 28.2
MCHC- 33.8
RDW-15.4
RBC-3.51
PLT-1.6
RBS- 136MG/DL
Blood urea- 69
Creatinine- 1.4
Na- 141
K- 3.0
Cl- 98
BGT- B positive
CUE
Albumin ++
Sugars ++++
Pus cells 4-5
Epithelial cells 2-4
RBCs NIL
LFT
TB- 1.14
DB- 0.50
AST- 86
ALT- 51
ALP- 69
TP- 5.1
ALBUMIN- 3.26
A/G- 1.77
Serum Amylase- 116
ECG:
Impression: Grade II Fatty Liver
CXR:
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