GENENERAL MEDICINE - CASE HISTORY - 4
78.Shalini ,65.Sushmitha
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This is a case of a 30 year old male patient lorry driver by occupation. He is a chronic alcholinic since 10years (90 - 180 ml/day) &non smoker. Patient started binge drinking past 2 months after his sister marriage. One month ago, patient only had alcoholic binge intake (180 - 400ml/day) for approximate 2 months without repeated food intake in between. Patient even stopped going to work. Last intake was one month ago.
Chief Complaint:
Loose stools since 1month
Fever since 20 days (low grade, chills)
Yellowish discoloration of eyes since 20 days
Weakness,loss of appetite, SOB since
History of present illness:
Patient complaints of loose stool 3 to 4 episodes , watery, accarnal black stools since one month. Also with pain abdomen and in umbilicus. Also associated with decreased urinary output & burning Micturation associated with fever and it is intermittent low grade & associated with chills.
History of past illness:
Yellowish discoloration of eyes since 20 days. Fever associated with generalized weakness & loss of appetite & SOB grade 2 since 20days .
No h/O vomiting, pedal edema, orthopnae &PND.No palpitations.
Personal history:
Diet :Mixed.
Appetite : normal
Sleep:Adequate
Bowel &bladder movements:loose stools
Burning Micturation.
Addiction:
Chronic alcoholic since 10 yrs.
Treatment history :
No history of drug allergies
H/O of blood donation 3 times.
Family History:
No history of similar complaints in the family.
Physical Examination:
General
Pallor
Icterus
Dehydration
No cyanosis
No lymphadenopathy
No clubbing
Blackish discoloration of hands since 1year
Tongue is dry &blakish discoloration
Knuckle Hyperpigmentation.
Increased JVP
Vitals
Temperature
Pulse rate 120bmp
BP 100/60mmHg
Spo2 98%
Systemic Examination:
CVS:
No thrills
Cardiac sounds S1, S2 heard
Presence of cardiac murmers
Respiratory System:
Dysponea
No wheeze
Position of Trachea - Central
Breath sounds vesicular
Abdomen:
Shape of abdomen- scaphoid
No tendernes
No palpable mass
Normal hernial orifice
No bruits
No free fluid
CNS:
Conscious
Speech - Normal
Cranial nerves, motor system, sensory system normal
Provisional Diagnosis:
Pancytopenia increased evaluation (B12 deficiency) - secondary to chronic alcoholism.
Investigations:
Hemogram
Reticulocyte count
Prothrombin time
Blood sugar - Random
Serum iron
Blood urea
LDH
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