A 30 year old male

A 30 year old male
November 23, 2022
 This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 



A 30 year old male patient resident of Gudipally came to the casualty on 23/11/22 of altered behaviour since yesterday

  Involuntary micturition since yesterday

Giddiness since morning

HOPI.

Patient was apparently asymptomatic till 12 am last night then he started behaving abnormally which was sudden in onset in terms of not .responding when spoken to,irrelevant talk which is repetitive and self talking.patient is irritable every few minutes and abuses family members at times.

Patient had history of alcohol consumption since 10 years currently 6 to 10 units daily throughout day,reports craving for alcohol, sweating and trembling when he doesn't consume alcohol.patient stopped consumption for the past 10 days till yesterday but was given 3 units I/v/o tremors

@ 10:30 am which subsided after consumption . patient.also reported double images and slurring of speech and memory disturbances since 10 days.patient reports consumption of tobacco in the form of smoking(10 cigarettes per day).

PAST HISTORY

H/O fall 1 month back ,sustained injury @ head.

N/K/C/O DM,HTN, TB ASTHAMA, EPILEPSY.

FAMILY HISTORY: not significant

PERSONAL HISTORY

DIET: Mixed

APPETITE: decreased

SLEEP: disturbed

BOWEL AND BLADDER MOVEMENTS: regular

ADDICTIONS: alcoholic since 10 years.

ON EXAMINATION.

Patient is conscious.

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema.

Temperature

BP: 120/80 mm hg

PR:68/min

RR:18/ min

SPO2:98% at room air.

GRBS: 98MG/DL.

SYATEMIC EXAMINATION

CNS.

HMF: orientation to place and person present and to time absent.

MEMORY: IMMEDIATE:

SHORT TERM.

LONG TERM:

PUPILS: NSRL

SPEECH: normal.

CRANIAL NERVE EXAMINATION: INTACT

SENSORY SYSTEM NORMAL

MOTOR SYSTEM

                        RIGHT. . LEFT  

TONE. UL Normal normal

               LL. Normal. normal

POWER. UL. 4/5. 4/5

                    LL. 4/5. 4/5.



REFLEXES. RIGHT. LEFT

BICEPS. 2+. 2+

TRICEPS. 2+. 2+

SUPINATOR. 2+. 2+

KNEE. 2+. 2+

ANKLE. 2+. 2+

PLANTAR. 2 +. 2+ 

SENSORY SYSTEM: normal.

CEREBELLAR SIGNS

FINGER NOSE TEST - IN COORDINATION PRESENT

FINGER FINGER TEST- IN COORDINATION PRESENT

ROMBERGS - NEGATIVE

DYSDIADOKINESIA- NEGATIVE

GAIT - NORMAL

CVS examination:

S1, S2 are heard.

No murmurs.

Respiratory system examination:

Inspection: Chest is moving bilaterally symmetrical. No pulsations.

Palpation: Trachea is central in postion.

Percussion: Resonant 

Auscultation: Breath sounds are vescicular.

Abdomen examination:

Inspection: Shape is scaphoid.

                    Movements are equal.

Palpation: No tenderness

                   Normal temperature

                   No organomegaly.

Percussion: Normal.

Auscultation: Bowel sounds heard.

INVESTIGATIONS.
DIAGNOSIS:.
TOBACCO DEPENDENCE SYNDROME WITH DIABETES MELLITUS AND HYPERTENSION.

TREATMENT:

1.IVF( NS,RL @ 75 ML/ HR

2. INJ THIAMINE 200 MG IV/ TID

3. INJ PAN 40 MG IV /OD/ BBF

4.TAB LORAZEPAM 2 MG PO/BD

5. INJ LORAZ 2 MG/ IM/ SOS

6.BP/ PR/ TEMP CHARTING 6 TH HRLY




Comments

Post a Comment

Popular posts from this blog

A 55 year old female patient came with chief complaint of shortness of breath

Image
A 55Yr old female with shortness of breath This is an 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 centered 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 plan. Cheif complaint: A 55yr old female patient residence of choutupal and agricultural by occupation with cheif complaint ofshortness of breath since 1 month and had an e
Read more

A 45yr old male c/o fever since 5 days. Abdominal pain, loose stools and vomitings

Image
A 45 yr old male c/o fever since 5 days.Abdominal pain , loose stools and vomitings CHIEF COMPLAINTS :    A 45 yr old male c/o fever since 5 days, abdominal pain , loose stools and vomitings since yesterday. HOPI: patient was apparently asymptomatic 5 days ago and then developed fever, which is low grade, not associated with chills and rigors and relieved on medication. He complains of diffuse pain abdomen since 11th October morning. He had 3-4 episodes of vomiting on the same day evening, food particles as content and non- bilious in nature .He had loose stools since evening the same day, which is of 5 -6 episodes and so he went to local hospital. He developed weakness of both upper and lower limbs and found to be having low potassium, correction was done and the weakness got improved. He now came with c/o abdominal pain , vomiting and loose stools. PAST HISTORY Not a k/c/o DM, Hypertension, Asthma, epilepsy, CAD, CKD.  He went for a General checkup 6yrs ago, where he was diagnosed
Read more