A CASE OF 40 YEAR OLD MALE WITH ALCOHOL DEPENDENCE AND FATTY LIVER





' Hello, I am Tejaswi Uppalapati ,a 3rd semester medical student.  This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.




CHIEF COMPLAINTS

A 40 year old male resident of Nalgonda,who is a tractor driver and also farmer came hospital with chief complaints of 

Nausea ,vomiting,generalised weakness,shortness of breath since 10 days after consumption of alcohol 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 10 days back after which he started having weakness ,shortness of breath,vomitings-4 to 5 episodes which were nonprojectile , non bilious which were sudden in onset and occured after consumption of alcohol 

He avoided alcohol for 3 years and consumed before 10 days.patient has been binge  drinking throughout the day since 10 days 

When he doesn’t drink he presented with tremors,giddiness and craving for alcohol 

PAST HISTORY 

No past history of diabetes / hypertension/tuberculosis/epilepsy/CAD

PERSONAL HISTORY 

Patient is married 

Farmer by occupation 

Appetite-normal 

Mixed diet

Bowel movements-regular

Micturition-normal

No known allergies 

Chronic alcoholic and 

Tobacco consumption in chewing form since 10 years

FAMILY HISTORY 

No family history of diabetes/hypertension/TB/CAD/epilepsy 

PHYSICAL EXAMINATION 

A.GENERAL EXAMINATION 

Well built

Well nourished

No pallor

No icterus

No cyanosis

No clubbing of fingers

No pedal oedema

No lymphadenopathy

Mild dehydration


B.VITALS


Temperature - 98.8°F

Pulse - 86/min

Respiratory rate - 16/min

BP -130/90

SpO2-98%

GRBS-162mg%


SYSTEMIC EXAMINATION 

Cardio vascular system 

No thrills 

S1 S2 cardiac sounds present 

No cardiac murmurs


Respiratory system 

No dyspnoea

No wheeze

Position of trachea-central

Breath sounds-vesicular


Abdomen 

Shape of abdomen -scaphoid

No tenderness 

No palpable mass

Hernial orifices-normal

No free fluid

No bruits

Liver-Palpable 

spleen-not palpable

Normal bowel sounds


Central nervous system 

Conscious

Normal speech

No signs of meningeal irritation 

Normal cranial nerves function 

Normal motor system function 

Normal sensory system function 


Reflexes 

Present and normal 


Provisional diagnosis 

Alcohol dependency 


Investigations



 

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