Name: K.Sannith Reddy
Roll no. 65
I've 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.
Following is the view of my case :
cheif complaints :
36 year old male Barber by occupation
resident of Saidabad- complains of alcohol.
addiction came for deaddiction.
After coming, BP was noted 180 / 110mming PR:91bpm.
k/c/o HTN since 6 months and missed morning dose of Antihypertensive
c/o burning pain the in epigastric region since1 month
c/o decreased appetite since one year
No H/o Fever; cough; cold
No H/o chest pain, palpitations; Sweating; SOB; orthopnea; PND
No H/ loose stools; Nausea, vomiting.
No H/o Burning micturition.
HISTORY OF PAST ILLNESS
k/c/o HTN since 6 months
N/k/c/o DM/THYROID/EPILEPSY/CAD/TB/ASTHMA/CVA
PERSONAL HISTORY:
Barber by occupation
Diet - mixed
Appetite- decreased
Bowel and bladder movements regular
sleep- disturbed
Addictions:
Alcohol consumption since 5 years 1/2 bottle per day
cigarette smoking since 9 years 3 per day
ALCOHOLIC HISTORY:
Patient didn't used to consume alcohol 5 years ago, then started drinking alcohol in the form of beer along with his friends. He continued to drink with his friends on special occasions and events. He gradually shifted to whiskey after 2 years. Currently Consuring about 12-16 units/day(1/2 bottle per day). Patent reports strong urge to take alcohol Patient experiences sleep disturbances and tremors when alcohol is stopped
He started neglecting his job and health and is interested in obtaining in alcohol instead. Continues to consume alcohol despite knowing its harmful consequences. About 2 months ago pt was admitted in Malakpet Deaddition center for about to days, but couldn't stay long without alcohol and felt the medication prescribed did not help him.
DRUG HISTORY:
On clinidipine 10mg and Telma H for hypertension since 6 months
FAMILY HISTORY:
Mother and father are known case of diabetes
Mother is a known case of hypertension too
Father was a social drinker died due to cardiac arrest
GENERAL EXAMINATION:
Pt is c/c/c
No pallor,icterus,cyanosis, clubbing, lymphadenopathy,edema
vitals:
temp - afebrile
pr: 91bpm,bp: 180/120 mm hg
rr:20 cpm spo2 98% at ra
grbs- 90mg%
SYSYTEMIC EXAMINATION:
CVS: S1, S2 heard no murmurs
RS: BAE presnt ,NVBS heard
P/A: soft,non tender
CNS: No focal neurological deficit
alcoholic withdrawal tremors present
PROVISIONAL DIAGNOSIS:
ALCOHOL DEPENDENCE, K/C/O HTN SINCE 6MONTHS , HYPERTENSIVE URGENCY
INVESTIGATIONS:
ECG: Showing LVH
TREATMENT GIVEN:
T. TELMA CT 80/12.5 MG PO OD
T. NICARDIA RETARD 10MG PO TID
T. THIAMINE 200MG PO TID
T. BACLOFEN XL 20MG PO OD
TAB LORAZEPAM 2mg 2 tab at night for 3 days
