Note - This is an a 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 centred 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.
6-08-2022
A 40 year old male came to OPD with chief complaints of weakness and shortness of breath since 10 days
HOPI
Patient was apparently asymptomatic 10 days back then he started having weakness and shortness of breath which was invidious in onset and accelerated on consumption of alcohol
He is taking alcohol since 10 days after abstaining for 3 years
Attender reported that he is consuming 24 - 26 units of alcohol since past 10 days
When he doesn't consume alcohol he is having trembling and giddiness and having cravings for alcohol recently
H/o smoking in the form of chewing since 10 days initially 1 pack per 2 days currently 1 pack per day and now he denies any cravings for tobacco
Past history
He was admitted in hospital a week ago ? Alcoholic delusions and then they given some medication which the patient did not take
No h/o head injury , seizures , hallucinations
Personal history
Takes mixed diet
appetite normal
Sleep adequate
Bowel and bladder regular
Addictions : a chronic alcoholic stopped drinking alcohol 2 years back and now he is continuing to take since 10 days
Consumes tobacco in form of chewing
General physical examination
Pt was conscious coherent cooperative moderately built and nourished well oriented to time place and person
Pallor Icterus cyanosis clubbing lymphadenopathy edema absent
Vitals
temperature : 98.6°F
PR : 80 bpm
BP : 110/70
RR : 19 CPM
Systemic examination
CARDIOVASCULAR SYSTEM - S1 and S2 present, No murmurs
RESPIRATORY SYSTEM - BAE +, NVBS
PER ABDOMEN - Soft and Non tender, No free fluid ,No palpable mass, No organomegaly .
CENTRAL NERVOUS SYSTEM - No focal neurological deficits
Investigations
Provisional diagnosis
Alcohol dependence syndrome with grade 3 fatty liver
Treatment
Inj. Thiamine 200 mg in 100ml NS i/v BD
Inj. Zofer 4 mg i/v TID
Inj. Pantop 40mg i/v OD
Inj.Optineurin in 500 ml NS i/v OD
Tab. Lorazepam 2 mg PO/BD
Moniter Vitals.
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