A 30 year old male

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


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 histoty, clinical findings, .investigations and come up with a diagnosis and treatment plan. 

LONG TERM:

PUPILS: NSRL

SPEECH: normal.

CRANIAL NERVE EXAMINATION: INTACT

SENSORY SYSTEM NORMAL

SENSORY SYSTEM: normal.

CEREBELLAR SIGNS

FINGER NOSE TEST - IN COORDINATION PRESENT

FINGER FINGER TEST- IN COORDINATION PRESENT

ROMBERGS - NEGATIVE

DYSDIADOKINESIA- NEGATIVE

GAIT - NORMAL

CVS examination:

S1, S2 are heard.

No murmurs.

Respiratory system examination:

Inspection: Chest is moving bilaterally symmetrical. No pulsations.

Palpation: Trachea is central in postion.

Percussion: Resonant 

Auscultation: Breath sounds are vescicular.

Abdomen examination:

Inspection: Shape is scaphoid.

                    Movements are equal.

Palpation: No tenderness

                   Normal temperature

                   No organomegaly.

Percussion: Normal.

Auscultation: Bowel sounds heard.

INVESTIGATIONS.



DIAGNOSIS:.

? ALCOHOL WITHDRAWL DELIRIUM

? ALCOHOL WITH DRAWL PSYCHOSIS

? ALCOHOL DEPENDENCE SYNDROME

TOBACCO DEPENDENCE SYNDROME WITH DIABETES MELLITUS AND HYPERTENSION.

TREATMENT:

1.IVF( NS,RL @ 75 ML/ HR

2. INJ THIAMINE 200 MG IV/ TID

3. INJ PAN 40 MG IV /OD/ BBF

4.TAB LORAZEPAM 2 MG PO/BD

5. INJ LORAZ 2 MG/ IM/ SOS

6.BP/ PR/ TEMP CHARTING 6 TH HRLY


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