CVA with Alcohol withdrawal related Seizures.



This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


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


Team:

Interns-

M Supriya 

Sowmya Kota

Mohitha

Amrutha 

Sanjay


Dr Durga Krishna PGY1

Dr Ajith Kumar PGY2

Dr Laxma Reddy PGY3

Dr Manasa PGY3 

Dr Vijayalaxmi (Ast prof.)


A 48 year old male shopkeeper presented with  

C/o seizures 4 days ago,

C/o altered sensorium from 2 days,

C/o aggressive behaviour with irrelevant speech from 2 days.


Patient was apparently asymptomatic 10 yrs back when he reduced alcohol intake following which he developed seizures- GTCS involving all four limbs with post ictal confusion.

No h/o tongue bite.

Not a/w involuntary micturition or defecation.


H/o similar complaints 1 yr back in February after stopping alcohol for 4 days during his son’s wedding. 


H/o fall while walking 10 days ago.

H/o similar episode 4 days ago after reducing alcohol intake. LOC+ for 15 mins, tonic clonic movements of both upper and lower limbs, uprolling of eyes+, frothing+, post ictal confusion+


PAST HISTORY:

H/o admission in de addiction centre in kims in 2018 for 15 days.

K/c/o pulmonary koch’s 1 yr back. Used medication for 6 months. 

K/c/o epilepsy from 10 yrs and was on medication - Tab.EPTOIN 100mg (1-X-2) for 9 yrs. Stopped medication from 1 year. 

Not a k/c/o HTN, DM, epilepsy, asthma,CVA.


PERSONAL HISTORY:

He is married and he has 2 sons.

He owns a General kirana store.

Reduced appetite.

Mixed diet.

Known chronic alcoholic from 30 yrs.

He used to drink whiskey 90ml/day increased to 720ml/day in 2 years.

 He used to drink Toddy 250ml once a month increased to 2 litres 4 times a week.

H/o tobacco chewing from 25 yrs- 1/2 pack per day increased to 5 packs per day.

Reduced sleep.

Normal bowel and bladder movements.

No known allergies.


O/E-

 Patient is conscious, irritable state at admission

Icterus+


No pallor, cyanosis, clubbing, pedal edema, generalised lymphadenopathy.






Vitals:

Bp- 110/70mmhg

Pr-132bpm

Rr-22cpm

Grbs-114mg%

Spo2-98%


SYSTEMIC EXAMINATION:

CVS- S1S2 +

          No murmurs.

RS- BLAE+ 

        NVBS+

P/A- soft, nontender.

        No organomegaly.

        Bowel sounds+





CNS- 

HIGHER MENTAL FUNCTIONS-are intact


All CRANIAL NERVES are intact

MOTOR SYSTEM
1) Nutrition - normal
2) Tone - Both upper limbs and lower limbs tone normal
3)Power- 5/5 in both upper and lower limbs
4)Reflexes
Superficial reflexes- intact
Deep tendon reflexes

Reflexes.   Right.      Left.  

Biceps     ++            ++

Triceps    ++            ++

Supinator  -               -

Knee       ++             ++

Ankle      ++             ++

Plantar   Flexion     Flexion











SENSORY SYSTEM
Spinothalamic- intact
Dorsal column - intact
Cortical sensations -intact

CEREBRLLAR FUNCTION TEST
Finger nose test-normal
Knee heel test-normal
Dysdiadokokinesia-normal

Psychiatry referral: 






             





INVESTIGATIONS:


            





MRI brain(done outside)- acute infarct in left paraventricular region with lacunar infarcts in b/l paraventricular region 


DIAGNOSIS-

CVA with acute infarct in left paraventricular region with lacunar infarcts in b/l paraventricular region with alcohol withdrawal syndrome.


TREATMENT:

1.Inj.Thiamine 100mg/IV/BD IN 100ml NS.

2.Inj. Optineuron 1 amp in 1 unit NS/ IV/OD.

3.Tab. Eptoin 100mg/PO/BD.

4.Inj.Pantop 40mg/IV/OD.

5.Inj.Lorazepam2cc/IV/SOS.

6.Inj.Aspirin 75mg PO/OD.

7.Inj. Clopidogrel 75mg PO/OD.

8.Tab. Atorvastatin 40mg/PO/OD.

9.Tab. Lorazepam 2mg 2 tablets PO/OD.

10.Inj. Mannitol 100ml IV stat.







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