Encephalopathy with decreased Sodium levels (42 year old man) GM CASE 1

17th August 2022
CASE STUDY 1

Hello, I am Saloni .S. Gangotri , a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

CASE SHEET:

CHIEF COMPLAINTS:
c/o 
- generalised weakness and drowsiness since the past 10 days.
- fever since 10 days.
- vomiting since 10 days.


HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 1 year ago and then developed involuntary movements of both upper limb and lower limb with rolling of eyes for which he was taken to hospital and diagnosed to be having alcoholic encephalopathy.

Patient's sodium level decreased and was admitted to hospital for further investigations and was conservatively further investigated.
 
He was asymptomatic until 10 days back.

But again developed low grade fever relieved with medication, generalised weakness and episodes of emesis twice a day containing food particles, acid content associated with nausea.


ASSOCIATED DISEASES:

———


PAST HISTORY:

h/o alcoholic encephalopathy with seizures 1 year back.

Not a K/C/O,
No Diabetes Mellitus (DM)
No Hypertension (HTN)

Similar episodes 1 year ago.

PERSONAL HISTORY:

Normal appetite with Regular Bowel movements. 

Has normal micturition with no burning sensation.

Has no known allergies.

Is a chronic alcoholic with gutka usage.


FAMILY HISTORY:

Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancers.


DRUG HISTORY:


GENERAL EXAMINATION:

-No palor
-No cyanosis 
-No lymphadenopathy
-No icterus
-No edema of feet
-No clubbing of fingers

-Is Malnourished.
-Mild Dehydration
-Temp - 98.6°F
-GRBS - 84mg%





VITALS:

Temperature: 

Pulse: 86 beats per minute

Respiratory rate: 16 cycles per minute

Blood pressure: 90/70 mm of Hg

SPO2: 98

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 present 

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular? yes

Abdomen:

Shape: Scaphoid
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Drowsy, awaken on arousal 
Speech: delayed response 

INVESTIGATIONS:
Biochemical investigations:


TPR GRAPHIC SHEET:


PROVISIONAL DIAGNOSIS:
—

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