43 MALE ALCOHOLIC CAME TO DE-ADDICTION CENTRE
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
CHIEF COMPLAINTS:
43 male business man by occupation resident of Haliya brought with complaints of :
Alcohol consumption since 10 days(increased consumption since 5 days - 2 full bottles per day
Background History:
Consuming alcohol since 15 yrs started with arrak and toddy gradually shifted to whiskey.reports consumes alcohol since 10-15 days approx.2 full bottles/day stopped due to force of family members 1-2 yrs.patient was completely abstinent for an year till last 10 days.
HOPI:
Patient was apparently asymptomatic 10 days ago then started drinking beer in a family function due to family and peer influence then continued drinking approx. 2-3 bottles of beer/day shifted to whiskey since 5 days ago and gradually started consuming upto 2 bottles per day.Reporta consumed 1 bottle yesterday due to gastric discomfort and approx.360ml today morning at 6 am.
Experiences sleep disturbances, palpitations,anxiety if he doesn't consumes alcohol.
Desire to consume alcohol present.
Not going to work since 10 days.
Consumes Alcohol knowing it's harmful effects
Reports continued consuming alcohol due to intense desire to consume alcohol and withdrawal symptoms.
No other substance abuse
No h/o head injury,seizures,loss of consciousness
No h/o blood on stools and vomitus
No h/o pervasive low mood , suicidality
No h/o grandiosity and flight of ideas
No h/o repetitive thoughts and actions
No h/o hearing of voices self talking behaviour
Currently complaining of epigastric pain and nausea.
Past history:
H/o DAC admission in kims narketpally 10 yrs ago
H/o HTN since 2yrs and on regular medication
Not a k/c/o DM,Asthma, Epilepsy,CVA,CAD, thyroid disorders
No h/o other psychiatric illness in the past.
Family history:
Attender reports his whole family of patient consumes alcohol including his father,mother,4 sisters and 3 brothers
Personal history:
Sleep-Normal
Appetite-decreased since 3 days due to nausea
Bowel and bladder movements - regular
General Examination:
Patient is drowsy,co operative
Moderately built and nourished
No pallor, icterus, cyanosis clubbing,Lymphadenopathy and edema
Vitals:
BP:110/70mm Hg
PR:88bpm
RR:18cpm
Spo2:98% on RA
Temp: 97.3
MSE(Mental status examination):
Patient is lying on bed comfortably , responding appropriately to oral commands, slightly drowsy and giving approximate answers, occasionally slightly restless and agitated
ETEC(Eye to eye contact)-positive and sustained
PMA(psychomotor agitation)-slightly increased
Speech- normal, relevant and coherent
Thought -cravings for alcohol present
Mood- Andholanagaundi
Affect- slightly agitated
Perception -NAD
Oriented to time, place and person
Systemic Examination:
CVS:
Jvp not raised
Inspection:
Shape of chest - elliptical
No visible pulsations
No engorged veins and scars
Apical impulse not visible
Palpation:
Apex beat present over the left 5th intercostal space 1cm medial to midclavicular line
No parasternal heave
No precordial thrill
No dilated veins
Auscultation:
S1 S2 heard ,No murmurs
Respiratory system:
Upper respiratory tract - normal
Lower respiratory tract-
Inspection:
Chest bilaterally symmetrical,
Shape- elliptical
Trachea- Midline
Palpation:
Trachea is Midline
Normal chest movements
Vocal fremitus is normal in all areas
Percussion: in sitting postion
Rt. Lt
Supraclavicular. N(resonant). N
Infraclavicular. N N
Mammary region. N. N
Axillary region. N. N
Infra axillary region. N. N
Supra scapular region. N. N
Interscapular region. N. N.
Infrascapular region. N. N
Auscultation:
Normal vesicular breath sounds
No added sounds
Vocal resonance is normal in all areas
CNS :
Higher motor functions - intact
Cranial nerves - intact
Motor system:
Rt- UL. LL. Lt- UL. LL
Bulk - normal N. N. N
Tone - N. N. N. N
Power - 5/5. 5/5. 5/5. 5/5
Reflexes:
UL LL
Biceps. 2+. 2+
Triceps. 2+. 2+
Supinator. 2+. 2+
Knee 2+. 2+
Ankle. 2+. 2+
Plantar-flexion flexion
Sensory system: intact
Co ordination is present
Gait is normal
No Cerebellar signs
No signs of meningeal irritation
Per Abdomen:
Inspection:
Shape - scaphoid
Umbilicus - inverted
All quadrants moves equally with respiration
Palpation:
All inspectory findings are confirmed
No local rise of temperature
Abdomen is soft and non tender
spleen and liver -not palpable
No other palpable masses
Hernial orifice are free
Percussion:Resonant
Auscultation:
Bowel sounds heard
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