44 male with jaundice, sleeplessness,knee pains , loss of appetite since one month

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

Patient came with c/o sleeplessness , yellowing of eyes, knee pains 

Patient was apparently asymptomatic one month back, then he developed graduall weight loss , psychotic behaviour like( talking irrelevant, beating his mom) wrist pains , knee pains so he was taken to hospital in nalgonda and used medication for 2 -3 days , he started to drink again, so then the took to another hospital in miryalaguda , he was said to have gallstones, renal stones, and jaundice so they brought here to kamineni

Past h/o denovo , dm type 2

No htn, asthma, cva cad, throid

Personal history:

He started to have alcohol from 3 years every day 2 quarters daily ( stressor: financial problems) , since one months he is having the cheif complaints , he had graduall weight loss of 10 kgs since past one year

Before 3 years: patient is auto driver ,he used to take care of his family financially, and 

 Since when he had alcohol, his son is taking care of the family financially, and the patient wasn't going to any work, he has decreased appetite, 

bowel and bladder regular, yellowish urine since one month

O/e :

Pt is c/c/c 

Bp : 120/80 mm hg

Pr 82 bpm

Cvs s1s2 heard

Rs b/l ae+

P/a : soft non tender

Cns : patient is conscious drowsy

Investigations:

Diagnosis

Alcoholic liver disease

Alcohol dependence syndrome

Tobacoo harmful use

Treatment :

Inj. Thaimine 200 mg 1 amp in 100ml ns iv tid

T.lorazepam 2mg 

T.baclofen x l 20 mg

Nicotine gums 2mg