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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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
6-08-2022
A 40 year old male came to OPD with chief complaints of weakness and shortness of breath since 10 days
HOPI
Patient was apparently asymptomatic 10 days back then he started having weakness and shortness of breath which was invidious in onset and accelerated on consumption of alcohol
He is taking alcohol since 10 days after abstaining for 3 years
Attender reported that he is consuming 24 - 26 units of alcohol since past 10 days
When he doesn't consume alcohol he is having trembling and giddiness and having cravings for alcohol recently
H/o smoking in the form of chewing since 10 days initially 1 pack per 2 days currently 1 pack per day and now he denies any cravings for tobacco
Past history
He was admitted in hospital a week ago ? Alcoholic delusions and then they given some medication which the patient did not take
No h/o head injury , seizures , hallucinations
Personal history
Takes mixed diet
appetite normal
Sleep adequate
Bowel and bladder regular
Addictions : a chronic alcoholic stopped drinking alcohol 2 years back and now he is continuing to take since 10 days
Consumes tobacco in form of chewing
General physical examination
Pt was conscious coherent cooperative moderately built and nourished well oriented to time place and person
Pallor Icterus cyanosis clubbing lymphadenopathy edema absent
Vitals
temperature : 98.6°F
PR : 80 bpm
BP : 110/70
RR : 19 CPM
Systemic examination
CARDIOVASCULAR SYSTEM - S1 and S2 present, No murmurs
RESPIRATORY SYSTEM - BAE +, NVBS
PER ABDOMEN - Soft and Non tender, Scaphoid shaped abdomen ,
No free fluid ,
No palpable mass,
No organomegaly .
CENTRAL NERVOUS SYSTEM - No focal neurological deficits
Investigations
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