43 year old male with alcohol withdrawal seizures

 43 year old male tailor by occupation came to the casuality with chief complaints of two episodes of seizures since today(15/12/21) morning.

History of present illness:

Patient is a known case of alcoholic since 20 years with the daily intake of 180 ml since 2 years.
Patient was apparently asymptomatic 5 months ago and then he sustained an injury to the right lower limb while going on bike for which the RMP has adviced him to stop alcohol intake and told him that his injury is not healing because of diabetes and started him on Oral hypoglycemic drugs.
3 to 4 days after starting oral hypoglycemic drugs and stopping alcohol there was history of giddiness and fall, deviation of mouth, loss of consciousness lasting for 2 minutes and the RMP has asked him to stop taking the OHAs as he had become hypoglycemic (<100).
Today morning at 9.30 am, patient had sudden onset of giddiness followed by loss of consciousness and tonic clonic movements of all 4 limbs, frothing and postictal confusion for 1 hr.
At 1.30 pm, patient had 1 more episode of seizure with tongue bite and frothing.
Patient had alcohol 2 days ago and reports withdrawal tremors and craving.

Past history:

Dignosed with Diabetes mellitus 5 months ago,not on medication.
Not a k/c/o HTN,asthma,TB,CAD,CKD.

Personal history:

Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder movements-regular
Daily alcohol consumer since 20 years-from last 4 years,180-270 ml of whiskey daily.Last binge was 2 days back.
Tobacco chewing since 15 years-3 packs/day.Last was 1 pack today morning.

Family history:

Not significant

General examination:

Patient is conscious,coherent and cooperative.
No pallor, icterus, cyanosis,clubbing,lymphadenopathy,edema

Vitals:

Temperature-98 F
PR-90 bpm
RR-18 cpm
GRBS-230 mg%
SpO2-98 % @ RA

Systemic examination:

CVS-S1,S2 heard,no murmurs.
RS-BAE +
CNS
HMF intact
Cranial nerves-normal
EOM-full
Pupils-B/L NSRL
Motor system:
Power         Right       left
Upper limb:5/5          5/5
Lower limb:5/5          5/5
Tone
Upper limb:normal    normal
Lower limb:normal    normal
Reflexes
Biceps       2+              2+
Triceps      2+              2+
Ankle         2+              2+
Knee          2+              2+
Plantar      flexor       
Romberg's test-negative
No nystagmus

Clinical images:

Injury to right lower limb 5 months back.

Injury sustained during seizure episode. 

Tongue bite and trauma to the nose during seizure episode. 

Investigations:

CBP:

Hb-9.9 g/dl

TLC-3,600 cells/cu.mm

N/L/E/M-76/14/2/8 

Platelet count-1.5 lakhs/cu.mm 

Peripheral smear-normocytic normochromic anemia with leucopenia.

RBS:219 mg/dl

LFT:

TB-4.42 mg/dl

DB-2.97 mg/dl

AST-166 IU/L

ALT-58 IU/L

ALP-356 IU/L

TOTAL PROTEINS-5.9 g/dl

ALB-2.97 g/dl

A/G RATIO-1.01

RFT:

Urea-12 mg/dl

creatinine-0.7 mg/dl

Uric acid-4.7 mg/dl 

Calcium-9.7 mg/dl

Phosphorus-1.6 mg/dl 

Sodium-141 mEq/l

Potassium-2.6 mEq/l

Chloride-96 mEq/l

Sr.Magnesium:2 mg/dl 

Repeat Sr.potassium-3.1 mEq/l

CUE:

Albumin-nil

Sugars-nil

Pus cells-2-3

USG Abdomen and pelvis:

Provisional diagnosis:

Alcohol withdrawal seizures with DM 

Treatment:

INI.LEVIPIL 1G IV STAT GIVEN

W/F SEIZURE ACTIVITY 

INJ.LORAZ 2CC IV SOS

INJ.THIAMINE 100MG IN 100ML NS IV INJ.LEVIPIL 500MG IV BD IN 100ML NS

GRBS MONITORING 6TH HRLY

TAB.LORAZEPAM 2MG STAT

SYP.POTCHLOR 10ML BD