35 year old male came with C/o occasional palpitations and SOB since 3 months.

 35 year old male came with C/o occasional palpitations and SOB since 3 months.

June 04, 2023

 This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning. 



DEIDENTIFICATION - 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.


CASE DISCUSSION -

35 year old male came with C/o occasional palpitations and SOB since 3 months.


HOPI-

Patient was apparently asymptomatic 3 months back, then started developing occasional palpitations, relieved on consuming alcohol, not a/w chest pain.

He developed SOB since 3 months, Grade 2, insidious in onset, gradually progressive, no aggravating and relieving factors.

C/o decreased appetite since 2 months. 

C/o generalised weakness since 10 days.

No H/o orthopnea and PND.

No C/o fever, decreased urine output, burning micturition, pedal edema. 


PAST HISTORY-

Not a k/c/o DM, HTN, CVA, CAD, TB, Epilepsy. 


PERSONAL HISTORY-

Addictions- Patient is a regular drinker since last 15-16 yrs, drank 180mL whisky every evening. 

Then 5 months back had sudden resistance to alcohol, started feeling disgusted even at the sight of alcohol so he left alcohol for 1 month. 

After 1 month he started developing tremors, palpitations which subsided on drinking, so gradually started drinking more, currently drinking 360mL to 540mL of whisky daily. 

No other addictions. 

Appetite- Decreased 

Diet: Mixed

Sleep: Adequate 

Bowel and bladder movements: Regular 


Family History: 

Not significant. 


General Examination -

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

He is conscious, coherent and cooperative.

Built & nourishment-Moderate

Icterus - Present

No pallor 

No cyanosis

No clubbing

No edema

No lymphadenopathy. 







Vitals: 

Temp: 98.1 F

Bp: 130/90 mmHg

PR: 106 bpm

RR: 20 cpm

SpO2: 98% on RA

GRBS: 164 mg% 


Systemic Examination -

CVS : 

S1 S2 present

No murmurs


RESPIRATORY SYSTEM;

B/l symmetrical chest

Trachea - Central

B/l air entry present

NVBS heard


ABDOMEN:

Shape of abdomen: Obese

Soft, non tender.

No rigidity or guarding.




CNS :

NFND, HMF intact

Reflexes - Normal

Investigations:














Provisional Diagnosis-
? Alcoholic Liver Disease 

Treatment- 
1) Inj. Thiamine 3 ampules 100mL IV/Stat followed by 100 mg in 100mL NS IV/TID
2) Syp. Potchlor 15mL PO/TID
3) Syp. Lactulose 15mL PO H/S

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