GM CASE 4

Name: Anusri
Roll no : 10
Introduction:
 45 yr old male came to gen medicine department with chief complaints of tremors, numbness in left lower and upper limb, dryness of mouth , loss of control , abdominal pain.
HISTORY OF PRESENT ILLNESS:
He was apparently asymptomatic 6 months back. He used to suffer from abdominal pain occassionally ( when he takes spicy food). He consulted doctor and took medicine. He got tremors on thursday morning 7:30 am as he did not consume alcohol. Tremors disappeared and became normal after consuming alcohol. He then took alcohol on friday and no symptoms seen. On saturday, he did not consume alcohol and he developed tremors, dryness of mouth, loss of control. He immediately went to RMP and took 2 injections. The symptoms did not diasappear. He then went to a private hospital. Ecg, RBS ,MRI,lipid profile tests were done and are completely normal. He was then reffered to KIMS hospital. 
Past illness:
No h/o DM HTN TB epilepsy asthma chromosomal abnormalities
No surgeries in the past
Personal history:
Married 
Diet: mixed
Appetite: normal
Bowel movements: normal
Bladder movements: normal
Sleep: normal
Addictions: alcoholic (since 25 years)
                    Non smoker
Family history:
Not k/c/o DM HTN TB asthma epilepsy
General examination:
No pallr
No cyanosis
No lymphadenopathy
No clubbing
No icterus
No oedema of feet
Temperature: 98.7F
Pulse rate: 74/min
Respiration rate: 18 per min
Bp: 110/70 mm Hg
Spo2 98%
Systemic examination:
CVS
No thrills 
S1S2 present
No murmurs
Respiratory examination:
No dysnopea
No wheezing
Position of trachea is central
Breath sounds are vesicular
Abdominal examination:
Shape of abdomen- scaphoid
No tenderness
No palpable mass
Hernial orifices are normal
No free fluid
No bruits
Liver not palpable
Spleen not palpable
Bowel sounds are present
CNS
llevel of consciousness- conscious
Speech normal
Signs of meningeal irritation:
    a) no neck stiffness
    b) no kernigs sign
Cranial nerves normal 
motor system normal
Sensory system normal
Glass gow scale normal
Reflexes
All are normal
Cerebral signs
Finger nose incordination - no
Kneel heel incordination - no
Provisional diagnosis: 
Alcohol dependent syndrome
Treatment:
Tab. LIBRIUM 25 mg
Tab. BENFOTHIAMINE 100mg
Tab. BACLOFEN 20 mg
Plan of care : conservative






Comments

Post a Comment

Popular posts from this blog

GM CASE-3

Image
Name : A.Anusri Roll no :10 Introduction: A 47yr old female patient house wife  residing in narketpally came with complaints of adbominal distension, pedal oedema and shortness of breath Chief complaints: Abdominal distension since 2 months Pedal edema since 2 months Shortness of breath since 2 months History of present illness: She had abdominal distension and pedal edema since 2 months. She went to various local hospitals in nalgonda. She was diagnosed with hypertension and hypothyroidism after the necessary tests. She also used medication given by them. Pedal edema was subsided but not abdominal distention. So she came to KIMS for the treatment. She came to OPD 10 days back and she was given treatment for 1 week. Then she was admitted on 22/6/22 for further treatment. History of past illness: She is a k/c/o hypertension(since 2 months) , Diabetes mellitus(since 6 years) , thyroid (since 2months), diabetic nephropathy No H/O surgeries in the past Personal history: Married Appetite: n
Read more

BIMONTHLY ASSIGNMENT OCTOBER

Image
A.Anusri Roll no. 10 Question 1 Gastroenterology 1.https://vamsikrishnarollno16.blogspot.com/2021/10/a-case-of-64yrs-old-male-patient-with.html?m=1 COMPLETENESS:  •The case presented is correct with accurate data  CORRECTNESS : •The history of the patient,symptoms and signs have been listed well. The clinical images were provide with the laboratory investigations. USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES: All the investigations lead to the diagnosis of the case and better treatment of the patient. Hence, no diagnostic uncertainties were found. 2.https://63konakanchihyndavi.blogspot.com/2021/10/a-case-discussion-on-chronic-liver.html COMPLETENESS:  •The case presented is correct with accurate data.  •The case has completeness in all factors The case begins with the chief complaint the history of presenting complaints in a chronological order, past history, personal history is written well the vitals have been explained. •Icterus -present, oedema- present
Read more