Skip to main content

A 32 year old male with alcohol dependence syndrome & 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

Medicine case

CASE HSITORY AND CLINICAL FINDINGS 29 year old female patient came to the casualty with h/o consumption of rodentiscide paste / ratatol poisoning 6days back [ 10 gm - approx. containing 3% yellow phosphorus ] followed by complaits of 1 episode of fever with chills 4 days ago subscided with medication . complaints of vomiting since 4 days  2to 3 episodes per day ,food as contents complaints of  yellowish discolouration of eyes and body since yesterday associated with discolouration of urine and dcrease appetite since 2 days . patient visited to local RMP yesterday morning she under went investigations : her Hb 3.7 gmd /dl ,TB : 5.6 DB 3.2 AST 270 ,ALT 340 ,ALP 135 ,TP 6.4 ,albumin 3.9 globulin 2.5 complaints of burnung sensation in chest ,giddiness today morning associated with palpitations  so she was brought to our hospital, no history of loose stools, pain abdomen, bleeding gumsno discouluration of stools ,no h/o sob ,blood in stools ,h/o fever 7 years ago, she got test...
Post a Comment
Read more

medicine case

 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 79yr male presented to casuality with chief complaints of  pedal edema  since 10 days , shortness of breath since 5 days   Patient was apparently asymptomatic 10days back then came with c/o   Pedal edema since 10 days -pitting type ,shortness of breath since 10 days insidious in onset , grade 3(marked limitation in activity) ,Fever 7  days back which subsided ,Dry cough 7 days back which subsided. PAST HISTORY - K/c/o hTN since 10 yrs on  regular medication-telmisartan 40mg H/o CVA 10 yrs back for which he was treated.  Not a k/c/o diabetes , TB,asthama,cvd , ep...
Post a Comment
Read more

A 50 year old with sob,pedal edema

"This is an 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 patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment" A 50 year old female patient came to casuality with complaints of pedal edema since 3 months ,decreased urine output since 3 months ,shortness of breath since 3 days HOPI Patient was apparently asymptomatic 3 months back then developed fever -low grade not associated with chills Pedal edema 3 months ago Decreased urine output 3 months ago Sob -progressed to grade 4i Patient  was advised for hemodialysis but pt attendees were not willing Patient has been taking nsaids since past...
Post a Comment
Read more