20 YEAR OLD MALE WITH UNSTABLE GAIT

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input..


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan .


CHEIF COMPLAINTS 

Unstable gait and tremors since last 10 days


HISTORY OF PRESENT ILLNESSES 
patient was apparently asymptomatic 12 years ago then he started taking alcohol in the form of ARRACK for the first time with his friends and mentions that he enjoys drinking it , as it was available in his farm he started drinking every alternative day about 1-2 glasses a day

2 years later his mother passed away in a tragic accident and to alleviate that stress he started drinking heavily , 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 . 
He also complains of sleep disturbances,decreased appetite and sweating if he does not consume alcohol .

Patient also complains of visual hallucinations, tremors and pins and needles sensations .

His family then enrolled him in a deaddiction programme 

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


no history of any psychiatric conditions
no history of any head injury 
no history of any loss of consciousness
no history of any epilepsy or involuntary movements
No fever , vomiting or stiffness of neck 
No weakening of limbs , no wasting or thinning of muscles

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 had a history of fracture to the left arm following an accident resulted in him getting 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 is conscious ,coherent , cooperative , oriented to person, time and place 

Poorly Built and poorly Nourished .

Temp: Afebrile . 

BP : 130 / 90 mmHg 

PR : 87bpm 

RR : 18 cpm  

Pallor : absent 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

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 lability

MMSE 27/30

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : visual acuity is normal

3rd,4th,6th : pupillary reflexes present     Restricted range of motion present
Nystagmus present 

5th : sensory intact and  motor intact

7th : normal

8th : No abnormality noted.

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

11 th intact

12 th intact




MOTOR EXAMINATION: 


 Right                              Left
    UL     LL.                        UL           LL


BULK Normal Normal Normal Normal

 TONE normal normal normal normal

  POWER 5/5 5/5 5/5 5/5
 

Reflexes 

   BICEPS present 

   TRICEPS  present

   SUPINATOR present

   KNEE present

   ANKLE 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 



CEREBELLAR EXAMINATION:

Slight tremors present

Truncal ataxia present

Gait ataxia present 

  Finger nose test   : slightly altered


  Heel knee test  : slightly altered

  Dysdiadochokinesia  absent


Nystagmus present


SIGNS OF MENINGEAL IRRITATION: absent


GAIT:

wide based gait while walking, unsteady with a tendency to fall and swaying towards the sides

unable to perform tandem walking



CVS :  apex at normal position ,S1,S2 + ,no murmurs 

RS :    
Chest shape normal  
 Trachea central
BAE Present 
Normal vesicular breath sounds

P/A :
 Soft and Non tender
No organomegaly present 

INVESTIGATIONS ( abnormal fundings)

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 sized liver with increased echogenicity and partially distended gallbladder - indicative of grade 2 fatty liver

PROVISIONAL DIAGNOSIS

1. wernickes encephalopathy ( B1 DEFICIENCY)

2. Cerebellar degeneration secondary to alcohol consumption 

3. Alcohol withdrawal 

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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