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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







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