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

 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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