case of 45 year old male came for deaddiction of alcohol and tobacco dependence syndrome

CHEIF COMPLAINTS:

Came for deaddiction of alcohol and tobacco on march 4th

HISTORY OF PRESENTING ILLNESS

 patient was apparently asymptomatic 10 years back and and started drinking alcohol quarter a day and one pack of cigarette and 5 years back he got admitted in kims for 40 days for deaddiction of alcohol and tobacco and he stopped drinking for 6 months and he started to take alcohol again daily and since one year he is taking 540 to 700ml of alcohol per day and 2 packs of cigarettes per day . 2 months back he got admitted in hospital at Ongole for deaddiction and stayed there for 3 days and stopped drinking alcohol for some days and continued to drink again.

He admitted in pyschiartry on march 3 for deaddiction of alcohol and tobacco and he developed weakness giddiness and fever and got admitted in gm department

Past history:

He has seizures since 15 years 

One episode for every 2 to 3 years 

Total no.of seizure episodes 6 times duration 5 to 10 mints, last episode of seizure is February 2021

Not a known case of diabetes mellitus and hypertension

PERSONAL HISTORY:

Diet:mixed

Appetite: decreased

Bowel and bladder: regular

Sleep: adequate

Addictions:

Alcohol=540 to 700 ml (4 quarters) per day ,cigarettes:2 packs per day

FAMILY HISTORY: no significant family history

GENERAL EXAMINATION: 

Patient is conscious coherent, cooperative

Temperature:

Bp:

Pulserate:

Respiratory rate:

Spo2:

pallor: present

Icterus: present


No clubbing lymphadenopathy and edema

SYSTEMIC EXAMINATION:

Respiratory system: no vesicular breath sounds heard

CVS s1 and s2 , no murmurs heard

GIT :soft ,non tender, liver palpable 




Cns: conscious coherent and cooperative well oriented to time and place

Speech-normal score 3 gcs inappropriate responses

No abnormality

Gait-normal

Reflex:++

Investigations

Ultrasound


CBP:

LFT:

RFT:

blood sugar:


PROVISIONAL DAIAGNOSIS:

decompensated alcoholic liver disease with hepatic encephalopathy with alcohol dependence syndrome and tobacco dependence syndrome 

Treatment:

Tab :benxl

Tab aldactone 25mg

Tab udiliv 300 mg

Tab Rifaximine 550mg

Syrup lactulose 10 ml

Tab oxazepam

Inj zofer

Inj thaimine 1amp in 100 ml of normal saline

Tab pan 40mg




































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