A32 year old male with alcohol dependence syndrome and Tobacco dependence syndrome


This is 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 patients clinical problems with collective current best evidence based inputs




A 32 year old male came to the opd with complaints of 
-Alcohol consumption since 6 years (540ml whiskey)
(Last consumption 180ml whiskey on 30/03/22)
-tobacco consumption since 6 years(6 packs gutka /day &1 cigarette /week)

ALCOHOL-
Cravings+
Tobacco + -Due to peer pressure and family stressors
Patient started consuming whiskey 90ml /day gradually increased it ti 540ml /day
Withdrawals+
Patient experiences sleep disturbances,palpitations when not consuming alcohol
Harmful use + Patient is aware of harmful effect of alcohol
Loss of control
Loss of interest in other pleasurable activities Patient is giving more importance to alcohol
TOBACCO-
Cravings+
Patient started chewing gutka 1pack/day,increased it to 6 packs/day in 6 years
Withdrawal +
Harmful use+
H/o use of ? tab .disulfuram 9months back for 3 days and stopped
No h/o seizures,blood in stools,RTA,persistent low mood ,suspicions,grandiosity
No h/o DM,HTN,BA,EPILEPSY, TB

GENERAL EXAMINATION -
Patient is Conscious, coherent,co operative well oriented to time,place,person
No pallor, No icterus, No Cyanosis, No lymphadenopathy, No edema


VITALS-
Height -176cm
Weight-72kgs
Temperature -98.6F
Pulse rate- 84bpm
Blood pressure-120/80mm hg
Respiratory rate -16cpm

SYSTEMATIC EXAMINATION:

CARDIOVASCULAR SYSTEM:
S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:
BAE present,NVBS

CENTRAL NERVOUS SYSTEM:
NAD

PER ABDOMEN:Soft, non tender
No guarding, No rigidity 
Bowel sounds present 


PROVISIONAL DIAGNOSIS-
ALCOHOL DEPENDENCE SYNDROME WITH TOBACCO DEPENDENCE SYNDROME 

INVESTIGATIONS 

CBP-
Hb-14.4gm/dl
Tlc-6,600 cells/cumm
Plt-2.48lakhs/cumm
Smear-NC/NC

 LFT:

TB :1.67mg/dl

DB:0.45mg/dl

SGOT :24IU/L

SGPT:15IU/L

ALP: 194IU/L

TP:6.7gm/dl

ALBUMIN-4.6gm/dl

A/G-2.19

RFT-

Creatinine-0.7mg/dl

Urea-25mg/dl

Uric acid 7.2mg/dl

Na+:143meq/L

K+:4.5meq/L

Cl-:99meq/L


RBS-108mg/dl

TREATMENT-

1.TAB LIBRIUM 25mg PO 1-x-2

2.TAB BENXL PO/OD @2pm

3.TAB BACFEN XL 20mg PO/BD 1-x-1

4.NICOTEX GUMS 4 mg PO/TID 1-1-1

5.CAP GASORAB PO/BD 1-×-1

Comments

Post a Comment

Popular posts from this blog

long case

Image
 This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. 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 a diagnosis and treatment plan. A 65 year old male patient came to OPD with the cheif complaint of loss of speech since one day History of present illness: Patient was apparently asymptomatic one month ago then he had fever with chills not associated with nausea , vomiting,head ache,loose stools, giddiness. Ne
Read more

26Y/M came to casualty with shortness of breath

Image
A 26year old Patient came to casuality with shortness of breath April 10, 2022 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. A 26 year old male patient, resident of adauidulpally, Nalgonda district farmer by occupation came to our hospital with chief complaints of - 1. Shortness of breath 2. Loss of appetite 3. Low grade Fever  4. Pedel edema Date of admission :- 05/04/2022 History of present illness:- Patient was apparently normal 1week back , then he had one episode of low grade fever, Generalized body pains, burning micturtion but relieved with medication.Then developed pedal edema,initially till ankle Loss of appetite  4-5 days back associated with
Read more