case history of 36 year old male
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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.
Chief complaint:
36 year old male, resident of suryapet came to the OPD with the Chief complaint of increased alcohol consumption since 2 yrs (daily 25units since 2 months) and increased cigarette smoking since 2 yrs(daily 20 cigarettes)
History of present illness: Patient had habit of consuming alcohol occasionally 2years back ,then he increased the consumption after due to family and financial stress to 25units
Binge drinking of continuously 15days then stops as he falls He will get treatment from local RMP nearby, then starts consuming alcohol from the day he becomes well
Tolerance present
Sleep disturbance,tremors,sweating early in the morning after consuming alcohol in the night(eye opener present)
Loss of control present
Blood vomitings 3 months back
H/o black colored stools 1 week back
Past history:
N/K/C/O HTN,DM,TB,CAD,ASTHMA
GENERAL EXAMINATION
Patient is Conscious, coherent,co-operative
No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema
VITALS
Temperature -98F
Pulse rate- 90bpm
Blood pressure-110/70mm hg
Respiratory rate -16cpm
SYSTEMATIC EXAMINATION:
PER ABDOMEN:Soft, non tender
No guarding, No rigidity
Bowel sounds present
CARDIOVASCULAR SYSTEM:
S1,S2 heard, NO Murmurs
RESPIRATORY SYSTEM:
BAE present,NVBS
CENTRAL NERVOUS SYSTEM: NAD
PROVISIONAL DIAGNOSIS-ALCOHOL DEPENDENCE SYNDROME WITH TOBACCO DEPENDENCE SYNDROME
INVESTIGATIONS
LFT:
TB :0.81
DB:0.9
SGOT :29
SGPT:56
ALP: 122
TP:6.6gm/dl
ALBUMIN-3.2gm/dl
A/G-0.96
RBS-76mg/dl
