Skip to main content

35/M with occasional palpitations and SOB


DEIDENTIFICATION - 
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CASE DISCUSSION -
35 year old male came with C/o occasional palpitations and SOB since 3 months.

HOPI-
Patient was apparently asymptomatic 3 months back, then started developing occasional palpitations, relieved on consuming alcohol, not a/w chest pain.
He developed SOB since 3 months, Grade 2, insidious in onset, gradually progressive, no aggravating and relieving factors.
C/o decreased appetite since 2 months. 
C/o generalised weakness since 10 days.
No H/o orthopnea and PND.
No C/o fever, decreased urine output, burning micturition, pedal edema. 

PAST HISTORY-
Not a k/c/o DM, HTN, CVA, CAD, TB, Epilepsy. 

PERSONAL HISTORY-
Addictions- Patient is a regular drinker since last 15-16 yrs, drank 180mL whisky every evening. 
Then 5 months back had sudden resistance to alcohol, started feeling disgusted even at the sight of alcohol so he left alcohol for 1 month. 
After 1 month he started developing tremors, palpitations which subsided on drinking, so gradually started drinking more, currently drinking 360mL to 540mL of whisky daily. 
No other addictions. 
Appetite- Decreased 
Diet: Mixed
Sleep: Adequate 
Bowel and bladder movements: Regular 

Family History: 
Not significant. 

General Examination -
Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
He is conscious, coherent and cooperative.
Built & nourishment-Moderate
Icterus - Present
No pallor 
No cyanosis
No clubbing
No edema
No lymphadenopathy.

Vitals: 
Temp: 98.1 F
Bp: 130/90 mmHg
PR: 106 bpm
RR: 20 cpm
SpO2: 98% on RA
GRBS: 164 mg% 

Systemic Examination -
CVS : 
S1 S2 present
No murmurs

RESPIRATORY SYSTEM;
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard

ABDOMEN:
Shape of abdomen: Obese
Soft, non tender.
No rigidity or guarding.

CNS :
NFND, HMF intact
Reflexes - Normal

Investigations-


Provisional Diagnosis-
? Alcoholic Liver Disease 

Treatment- 
1) Inj. Thiamine 3 ampules 100mL IV/Stat followed by 100 mg in 100mL NS IV/TID
2) Syp. Potchlor 15mL PO/TID
3) Syp. Lactulose 15mL PO H/S


Popular posts from this blog

28 year old female with right upper and lower limb weakness

Image
A 28 year old female came to OPD with chief complaints of weakness and pain in right lower limb and upper limb since 8 years. HOPI: Patient was apparently asymptomatic 8 years back then she developed weakness in right lower limb which is insidious in onset and gradually progressive,associated with pain.no tingling sensation. Pain in right side of the back radiating to right lower limb and no tingling sensation. Patient also had c/o headache which is on and off since 8 years.holicranial type,no tingling/numbness.no photophobia and no phonophobia. Progressive weakness of lower limb 1st in thigh then extended upto feet. Patient slowly developed difficulty in walking since then with changes in style of gait as weakness progressed in right lower limb. H/o trauma 8 years back-fall from bicycle after which she developed these symptoms. Past history: Patient gives history of trauma due to fall at the age of 5-6 years and had injury to nose and she had epistaxis-last episode was after the deliv...
Read more

Generalmedicine case discussion

Image
GENERAL MEDICINE CASE DISCUSSION  A case of 60 yr old female with a chief complaint of SOB N.VISHNU ROHITH REDDY ROLL NO:98 9th semister 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. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .   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 diagnosis and treatment plan. CASE DISCUSSION A 60 yrs old female patient presented with chief co...
Read more

Online blendid monthly assignment for the month of May 2021

Image
Neurology(A) A1. Evolution of the symptomatology:    apparently asymptomatic 9 days ago                                                              ⬇                                                  suddenly started talking, as well as laughing to himself               He was conscious, but oriented to time, person and place only from time to time              He was unable to lift himself off the bed and move around, and...
Read more