Skip to main content






 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 comments 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 a diagnosis and prognosis

A 40 year old male resident of athmakur daily wageworker by occupation came to the OPD with the chief complaints of 

CHIEF COMPLAINTS:


Complaints of swelling of face since 1 month

Compliants of lesions in the mouth since 1 month



HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 24 years back then he started taking toddy and then gradually shifted to take whiskey in next 6 months. Currently consuming 9 units per day (90ml) since the last 4 months. Patient has strong urge to take alcohol on waking up.he experiences increased sweating, tremors,sleep disturbances, restlessness and hearing voices when stopped consuming alcohol.he continues to take alcohol despite knowing it's harmful effects. Patient started smoking tobacco since last 5 years.experiences irritability and headache when tobacco  is stopped. He continues to smoke despite knowing it's harmful effects.

No history of vomiting, loose stools, burning mituration,foul smelling, head injury, palpitations, seizures.



PAST HISTORY 

Known case of peptic ulcer disease since 7 years and on medication.

Known case of diabetes mellitus since 2 years and on medication.

History of hallucinations 1 year back after stopping alcohol for 3 days.

Not a known case hypertension,TB, asthma,CHD,CVA, epilepsy, thyroid disorders.


PERSONAL HISTORY :

  1. Diet: mixed
  2. Appetite: decreased
  3. Bowel habits: normal
  4. Bladder habits: normal
  5. Sleep: decreased
  6. No history of allergies.
  7. Addictions:   alcohol consumption   Whisky(180ml) daily since 24 years.
  8. Smoking beedi 10 -12 per day since 5 years.      


FAMILY HISTORY : his father is also drunker.

His mother committed suicide 20 years back.

GENERAL PHYSICAL EXAMINATION:


Patient is conscious, coherent and cooperative, well oriented to time,place and person.

  • Pallor          - absent
  • Icterus        - absent
  • Clubbing    - absent
  • Lymphadenopathy    - absent
  • Cyanosis     - absent
  • Pedal edema  - absent









O/E :

Patient is c/c/c 

Temp:- 97.2 F

PR-  80bpm

BP- 120/80 mm of Hg

Spo2-

GRBS- 320 mg per dl


On abdominal examination:

Inspection:

Shape of abdomen is scaphoid 

Flanks are free

Umblicus is in position, everted 

Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.

No visible veins.

No engorged veins.

Movements of abdominal wall are normal, no visible gaatric peristalsis 


Palpation: 

Liver examination:

On superficial palpation

No tenderness , normal temperature

On deep palpation

No tenderness in liver

Non pulsatile


Spleen examination: 

No tenderness and pain


Percussion :

5. Tidal Percussion

 


Auscultation 

1. Normal bowel movements heard
2. Bruit – no renal artery bruit heard
                 no iliac artery bruit heard


CVS Examination :

Inspection :

No abnormal palsations

No visible scars.

No chest deformities.

Mediastinum normal

Trachea central in position.

Palpation :

Mediastinal position  : apex beat palpable in 5 th intercostal space.

 Position of trachea normal.

Percussion :



Ascultation : on examination of mitral area, pulmonary area, tricuspid area and aortic area S1 and S2 heard. No murmurs heard.

Respiratory system examination :

Mild anterior deviated nasal septum towards left side.


Inspection : 

Position of trachea central

No dropping off shoulders

No intercostal indrawing

No supraclavicular hallowness

Shape and symmetry of the chest normal.

No dilated veins. 

No visible scars.

accessory muscles of respiration not prominent.

Palpation : 

On three finger test : position of the trachea central.

Respiratory movements are normal.

Vocal framitus : on palpation of right and left sides in all the areas vibrations are normal on both sides.

On Percussion :

No cardiomegaly

Ascultation :

Vocal resonence : equal on both sides in all areas

Normal vesicular breath sounds heard.

Bilateral air entry present.


CNS  :



INVESTIGATIONS


Complete blood picture 

Random blood sugar

Liver function test

Renal function test

Blood grouping

ECG
 
Complete urine examination

HIV

HBsAg














PROVISIONAL DIAGNOSIS:

Alcohol and tobacco dependence syndrome with type 2 diabetes mellitus.

Treatment

Tab lorazepam 2 mg stay

Tab Baclofenac 2mg

Nicotine gums 2mg 

Tab glimipiride 2 mg OD 8 am before food.

Tab metformin 1 g OD after breakfast.

Tab sitagliptin OD at 2 pm after food + tab metformin 500 mg OD at 2 pm after food.

Comments

Popular posts from this blog

OSCE and learning points

45 years old female with shortness of breath