General medicine case-3

 This is an online elog book to discuss our patient de-identified health data shared after taking his/her /guardians signed informed consent.Here we discuss our individual patients 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 input.

Case:

An 42 year old male patient , GHMC worker by occupation was brought to the casualty with the Chief complaint:  acholol consumption since 10yrs and tobacco chewing since 10yrs

History of present illness:

Patient was apparently asymptomatic 10yrs back then he started consuming alcohol. Intially he would consume once a week later on it increased to 3 times a week. Patient lost his wife 6 yrs ago from then he started consuming alchol everydy.

Patient experience tremors, fearfullness,sleep disturbances, excessive sweating if stops consuming alcohol.

Personal history:

Diet: mixed

Appetite: normal 

Sleep: adequate

Bowel bladder movement : regular

Pernicious habits: alcohol since 10yrs

                                    tobacco since 10yrs

Past history: was admitted in the hospital due to abdominal pain.

He is a known case of hypertension and is under medication.

Family history: no relevant family history

General examination:

Patient is conscious , coherent and cooperative moderately built.

No pallor, cyanosis, clubbing, edema.

Vitals:

Temp: 97.5F

Spo2 : 97%

PR : 86 Bpm

RR : 21cpm

Bp: 110/90mmhg

Systemic examination:

CVS : S1 S2 heard, no murmurs, no added sounds.

Respiratory system: trachea is in central position

No dyspnoea.

P/A : soft , non - tender.

Investigation:

Provisional diagnosis: 

Alcohol dependence syndrome

Tobacco dependence syndrome.