36 Y M with alcohol dependence syndrome

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 inputs on the comment box"


I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan.


CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
Presenting complaints:

Patient came with the chief complaints of decreased sleep since 3 months.
Tremors of bilateral hands since 15 days.

HOPI:

Patient was apparently asymptomatic 3 back then he had decreased sleeps 2-3 hours in night.
Tremors of bilateral hands since 15 days.
H/o increased sweating 
No h/o shortness of breath,chest pain, palpitations.
No h/o fever,cold.
No h/o malena , haematuria.

Past history :
N/K/C/o DM type 2 , hypertension, TB, Epilepsy, CVA, CAD

Personal history:
Appetite: decreased
Sleep: inadequate
Bowels: regular
Micturition: normal
He had history of alcohol consumption since 17 years.
He used to work in army due to personal reasons he left the job and started to have more alcohol then before.
In 2017 he was admitted in ASHA hospital and got treated for 3 months. Then he stopped having consumption of alcohol for 3 months.
Then he started having alcohol.
During intoxication he has visual, auditory hallucinations.
3 suicidal attempts in 2015 due to personal reasons.

General physical examination:
Patient is conscious coherent and cooperative
PR 80 bpm
BP 120/70 mm hg
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Edema

Systemic examination:
Cardiovascular System 
 - no thrills
 - cardiac sounds S1 and S2 heard
 - no cardiac murmurs 

 Respiratory System 
 - no dyspnea
 - no wheeze
 - tracheal position is central
 - breath sounds : vesicular 
 - no adventitious sounds heard

 Abdomen 

  - shape : distended 
 - no scars, striae or engorged veins 
 - bowel sounds heard
 - no bruits, rubs
 - no shifting dullness
 - no fluid thrill
 - no palpable mass
 - hernia orifices : normal
 - liver: palpable
 - spleen : not palpable


CNS 
 - conscious
 - normal speech
 - cranial nerves
 - motor and sensory systems normal





Diagnosis:

Pancytopenia
Alcohol dependence syndrome currently in withdrawal

On 18/9/23



On  20/9/23
Vit B12 -826
Ferritin -24
Serum iron-73
Reticulocyte count -1.5
LDH-216

Treatment:
1.Inj thimanie 1amp (100 mg) in 100 ml NS IV/BD
2.Tab lorazepam 2mg po/TID
3.Tab baclofen xl 20 mg po/bd




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