CASE-4

Hi I am Siddharth fifth semester medical student.This is an online e block to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio.
 
A 35 yr male patient of carpenter in occupation and a resident of suryapet came to OPD with complaints of pain in the abdomen And SOB
CHEIF COMPLAINTS:
Pain in the abdomen since 3 months
Occasional palpitations since 3 months
shortness of breath since 1 month
Generalized weakness since 10 days
HOPI:
patient was asymptomatic 3 months ago then
Started developing palpitaions not associated with chest pain which is reduced on drinking alcohol. There is SOB which is of GRADE 1-2
Without association of orthopnea and PND
Pain is sudden  in onset, non radiating , no aggregating on consumption of food or during an activity, no releaving factors 
PAST ILLNESS:
generalized weakness since 10 days
Constipation is present 
No HISTORY of
Fever
burning micturation
Blood transfusions
No allegies
TB
ASTHMA
BP
DM
HTN
THYROID DISORDERS
PERSONAL HISTORY:
Appitite normal
Bowel movements: abnormal
Bladder movements: normal
No allergies
Mixed diet
Addictions:
Alcohol (Chronic drinker consumes 750 ml of whiskey 16-19 units  daily since 20 yrs and sometimes 20-21 units on any occasions and functions with friends and daily after work about 6-7 units and had a habit of drinking toddy around 4-5 units a day  at the age of 15 for 3 years)
Tobacco (snuff)
FAMILY HISTORY:
not significant
GENERAL EXAMINATION:
Patient is conscious co- operative and coherant
Moderately built
With 
Icterus  present 
 pallor 
No lymadenopathy
No pedal oedema
No clubbing
No cynosis
VITALS
temp- febrile 99 degree F
Pulse -103bpm with normal volume and rhythm 
RR- 23
B.p- 110/70 spm
Spo2 - 94%
CVS EXAMINATION:
S1 AND S2 heared
No cardiac murmurs
Mild tachycardia is present 
ABDOMEN EXAMINATION:
inspection
Abdomen - distended
With no scars and surgical marks
Palpation : tenderness present all over the body but more in the right hypochondrial region
Percussion: 
Fluid thrill is present
So shifting dullness
 No hernial orifaces
 No palpable mass
 tenderness is present 
 Liver is palpable dull note was heard on   percussion 
 Spleen not palpable
CNS EXAMINATION:
  neck stiff Ness -no
 TREMERS ARE PRESENT 
 SPEECH IS NORMAL
 MOTAR REFLEXES
 Knee jerk reflex preset 
 Elbow reflex present
 Biceps reflex present
 Triceps reflex present
 Ankle reflex present
 SENSORY REFLEXES ARE INTACT
 CRANIAL NERVES ARE INTACT

PROVISIONAL DIAGNOSIS:
 Alcoholic liver disease

TREATMENT:
 patient  is on deaddiction and on alcohol  withdrawal treatment:






 







 




 

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