a 57 yr old male with altered sensorium secondary to alcohol intoxication with hypokalemia

A  57 Yr old male patient presented to the casualty with chief complaints of slurred speech, right upper limb and lower limb weakness and altered sensorium since 1 day 

HISTORY OF PRESENT ILLNESS :-

Patient was apparently asymptomatic before 1 day and then the slurring of speech, weakness and altered sensorium developed which were sudden in onset and gradual in progression

Patient is a Shepherd by occupation and when he was with the animals in the evening, he collapsed suddenly after which he developed the weakness of his right upper and lower limbs. Initially after the collapse the patient was able to talk normally and was able to recognise individuals, but by night he developed slurring of speech and by the time he was brought to hospital he jad altered sensorium.

There is no H/O LOC, no ENT bleed

No H//O fever, burning micturition, loose stools

No H/O sob, palpitations, orthopnea, PND

Daily routine :-

Wakes up at 8am, he takes rice as his breakfast at 9 am and takes food along with him for lunch and goes to work at 10 am

1 pm lunch

5 pm back from work

5 to 8 snack stuff and bathing

8 pm dinner

9 pm sleep

PAST HISTORY :- 

Not a known case of DM,HTN,Epilepsy,TB and coronary artery disease.

There is history of amputation of the ring finger of right hand, due to trauma occurred during the time when he was working as a farmer 1 year back

PERSONAL HISTORY :-

Diet - mixed

Appetite - normal

sleep - adequate

Bowel and Bladder movements - regular

Addictions - Consumes saara since past 20 years, 2 - 3 glasses every day

Smokes a pack of beedi everyday, each pack contains 20 beedis

DRUG HISTORY : 

No significant drug history

FAMILY HISTORY :-

No significant family history

GENERAL EXAMINATION :-

Patient is conscious , incoherent ,incooperative

at the time of examination

He is examined in a well lit room, with consent taken.

He is moderately built and well nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent

Vitals :

Temperature - Afebrile

Pulse rate - 90 bpm

Respiratory rate - 19 cpm

Blood pressure - 90/60 mmHg

SpO2 - 98% on Room air

GRBS - 113 mg/dl

SYSTEMIC EXAMINATION :-

CVS :- S1 and S2 heart sounds heard

           NO murmurs and thrills

RESPIRATORY SYSTEM :- Bilateral air entry present position of trachea - central Vesicular breathsounds heard

CNS :- 

MMSE

Orientation - 0/5, 0/5

Registration - 0/3

Recall - 0/3

Attention A Calculation - 0/5

Language - 0/2

CRANIAL N. EXAMINCTION :-

1. CN

Sence of Smell - N

2. CN

visual acuity - N

3,4,6 CN

EOM movement - could not perform

Pupil size - 2, 3 mm

Direct light reflex/consensual light reflex/accommodation reflex - present, present

Ptosis - absent, absent

Nystagmus - absent, absent

5 CN

Sensory over face & buccal mucosa - N, N

Motor - masseter, Temporalis, pterigoids - N, N

Reflexes - Corneal,Conjunctival - N, N

7 CN

Motor

Nasolabial fold - equal on both sides

Occipito frontalis - equal on both sides

Orbicularis oculi - equal on both sides

Orbicular oris - equal on both sides

Buccinator - equal on both sides

Sensory:

Taste over anterior two third of tongue - cant be performed

8 CN - could not perform

Rinnes test

Webers test

9, 10 CN -

Uvula palatal arches movements - N, N

Gag reflex - N

palatal reflex - N

11 CN - could not be elicited

Trapezius

Sternocleidomastoid

12 CN

wasting - no

Fasciculations - no

Tongue protrusion to midline - midline

MOTOR SYSTEM EXAMINATION :- could not be performed

Power - could not be performed 

Trunk muscles - rolling over bed cannot br performed

Superficial reflexes -

Corneal - N, N

Conjunctival - N, N

Abdominal - N, N

Deep Tendon reflexes -

Biceps - 

R- 2+; L - 1+

Triceps -

R- 2+; L - 1+

Supinator -

R- 1+; L - 1+

Knee -

R- 1+; L - 1+

Ankle -

R- 0; L - 0

Cerebellar examination - could not be performed

SIGNS OF MENINGEAL IRRITATION: absent

Sensory System examination - could not be performed

Gait could not be done

involuntary movments - absent

uprolling of eyes - absent

involuntary micturition - absent

involuntary passage of stools - absent

frothing over mouth - absent

Examination of spine - normal

ABDOMEN :- Soft and non tender

            No palpable masses

            Bowel sounds heard 

            No organomegaly

INVESTIGATIONS :-

RFT :-

urea - 18

Creat - 1.3

UA - 5.5

Ca - 8.9

P - 2.5

Na - 134

K - 3.6

Cl - 98

LFT :-

TB - 1.81

DB - 0.51

SGOT - 15

SGPT - 8

AIP - 165

TP - 5.7

albumin - 3.04

A/G - 1.14

CUE :-

albumin - nil

Sugar - nil

Pus cells - 2,3

Epithelial cells - 2,3

ABG - 5/8/23

Ph - 7.36

pCO2 - 52.5

pO2 - 22.5

HCO3 - 22.5

O2 - 87.5

ULTRASOUND - impression -

Right renal calculi

Grade 1 RPD changes in right kidney

Grade 1 fatty liver

ECG -

TREATMENT:-

1.IVF fluids 2 units ns, @50ml/hr

2.INJ. KCL 2 amp, 40 meq in 500 ml ns in 4 hrs

3.INJ. THIAMINE IN 200 mg in 100 ml ns IV/BD

4.INJ. OPTINEURON in 100ml ns IV/OD

5.vitals monitoring 2 hrly, BP, PR, TEMP

PROVISIONAL DIAGNOSIS:-

Altered sensorium secondary to alcohol intoxication with hypokalemia