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


Popular posts from this blog

A 50 year old female patient with loin pain and pedal edema

Image
This is an online e-log book to discuss our patients de-identified health data shared after taking his/her/guardian's 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 patients clinical problems with collective current best evidence based inputs. 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. CHEIF COMPLAINT: A 50 year old female patient who is resident of athmakur mandal suryapet district and home maker came to the casuality with cheif complaint of lower back pain since 1 year and pedal edema si
Read more

A 42 YEAR OLD PATIENT WITH PALPITATIONS, SOB AND HEADACHE.

Image
 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.  A 42 year old male patient came with the  palpitations since  morning , difficulty in breathing since morning, Headache since morning ,Frothy urine 15-20 days ago (not present now) HISTORY OF PRESENTING ILLNESS- Pt was apparently alright till morning when he had  palpitations and SOB grade II. He also had complaints of headache which is diffuse.  nausea not a/w lacrimation/photophobia/phenophobia Since 15 days he has  frothy urine which was    intermittent , resolved now No  chest pain/ orthopnea/syncopal attacks No pain abdomen, loose stools, fever, constipation,burning micturition, vomitings No  tingling
Read more

NEPHROTIC SYNDROME WITH TYPE -I DM, HYPERTENSION,RIGHT PLEURAL EFFUSION

Image
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.  A 20 yrs old female who is a house wife was brought to the casualty on 23/10/2022 with the features of • Bilateral pedal edema since 1 months  •Shortness of breath (grade 2-3 ) since 1 months,which is insidious on onset gradually progressive not associated with orthopnea  •Decreased urine output since 10 days  •Swelling of lips since 3 days HOPI :- Patient was apparently asymptomatic 11years ago,then her parents observed her eating more food, increased urine output on a regular check up she was  diagnosed with diabetes type -1(On insulin since then)  2018-  Patient became drowsy and brought to the hospital
Read more