A 40 years male came to OPD with cheif complaints of vomitings and generalised weakness

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This is an online E - log book to discuss our patients 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 portfolio and your valuable inputs on the comment box.


A 40 years male came to OPD with cheif complaints of vomitings 5 episodes, nausea, generalised weakness, epigastric discomfort and shortness of breath on and off since 10 days

History of presenting illness:

Patient was apparently asymptomatic 10 days back after which he started having vomiting of 4 to 5 episodes per day associated with nausea, weakness and shortness of breath 2/3 which were sudden in onset

Patient attender reported that pt started consuming alcohol 10 days back after abstaining for 3 years

Attender informed that patient has been binge drinking almost of 24.36 units throughout the day since 10 days

When he dosent, he presents with trembling, giddiness and also reports craving for alcohol currently

Last drink was on 6/9 of about 3 units at 6 am morning

H/o tobacco consumption in chewing form 10 years, initially 1 pack per 2 days, currently 1 pack per day every day
Denies any craving for tobacco

Attender reports that pt was admitted for a day at hospital in suryapet a week ago for alcohol delirium where he was adequately treated and was started in medication which pateint did not take

No h/o head injury, seizures like activity, hallucinating behaviour


History of past illness:

Not a known case of DM/HTN/ Thyroid disorders, CAD, epilepsy.


General examination:

Temperature: 98.8 F
PR: 86/ min
RR: 16/ min
BP: 130/90
SpO2: 98%
GRBS: 162 mg%

Systemic examination:

A. Cardiovascular system :


• S1, S2 are heard
• No thrills and no cardiac murmurs

B. Respiratory system:

• No dyspnoea, no wheezing
• Position of trachea - central
• Breath sounds - Vesicular

C. Per Abdominal Examination:

Shape of abdomen - scaphoid
• No Tenderness 
• No palpable mass , free fluids, bruits
• Liver, spleen not palpable
• there are no Bowel sounds

D. Central Nervous :

Patients is conscious, coherent, cooperative and well oriented to time and space

Speech normal

No signs of meningeal irritation

Cranial nerves - intact

Sensory system - intact

Glassgow scale - normal


Provisional diagnosis:

Alcohol dependence syndrome with grade 3 fatty liver


Treatment:

6/9

Inj thiamine 200 mg in 100 ml NS IV/BD
Inj zofer 4 mg / IV / TID
Inj PAN 40 mg / IV/ OD
Inj Optineuron in 500 ml NS/ IV/ OD
Inj Lorazepam 2 mg / PO/ BD
Monitor vitals and inform SOS

7/9

Inj thiamine 200 mg in 100 ml NS IV/BD
IV fluids NS with 1 amp Optineuron/IV/OD
Inj zofer 4 mg / IV / TID
Inj PAN 40 mg / IV/ OD

Inj Lorazepam 2 mg / PO/ BD
Monitor vitals and inform SOS



Investigations:

ECG:
CUE:

USG:
Investigation result chart:

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