Alcohol induced hypoglycemia
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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.
A 55 year old male from Narketpally , farmer by occupation came to medicine opd on 15th July with CHIEF COMPLIANT OF
Weakness and vomitings for 3days since 12 july.
Decrease urine output and yellow in colour since 1day (15-07-22)
HOPI
Patient was apparently asymptomatic 3 days back then he started taking large quantities of alcohol for 3 days without food intake , started feeling lethargic , had 2 episodes of vomiting everytime after taking alcohol which is watery,non bilious,projectile.
He was counsious but unresponsive on that day
H/o slurring of speech on the day of admission.(15 July)
H/o decrease urine output and dark yellow in colour
Craving to alcohol is present but no h/o of withdrawal symptoms.
No h/o sweating, palpitations, sleep tremor
Daily routine
He wakes up at 5am and complete his daily routine and goes to farming by 8am after having a tea and eats food at 10 am.and returns home at 5pm and completes evening routine and he drinks alcohol daily from the past 5years about 90ml and have his dinner and sleep by 9pm.
Past history
No similar complaints in the past.
No h/o dm,htn,tb,asthma, epilepsy
Personal history
Diet-mixed
Appetite - no appetite for 3 days from 12 july, normal before and after.
Sleep -reduced
Bowel and bladder - uo decreased and yellow in colour.stools are regular
Addiction -consume Alcohol daily (beer 90 to 180ml)
General examination
I examined the patient with his consent in a well lit room in both standing and supine positions.
Patient was conscious, cooperative, coherent. Moderately built and nourished.
Pallor absent
Icterus absent
Clubbing absent
Cynosis absent
Generalised Lymphadenopathy absent
Edema absent
Vitals
Temperature: Afebrile
Pulse 106/min
BP: 110/70mmHg
RR-18/min
Spo2 99%
Abdominal examination:
Inspection: no scar ,no pulsation
Palpation :soft ,non tender, liver is palpable
Percussion:dullness felt from right intercoastal space to right subcoastal margin.
Auscultation normal bowel sounds
Rs: bilateral air present , normal vehicular breath sounds heard.
Cvs :s1 s2 heard ,no murmur
Cns: no focal neurogical deficient
Investigations:
Alcohol induced hypoglycemia with alcoholic liver disease.
Treatment
Inj . thiamine 200 mg iv tid
Heptagon od
Inj lasix
Inj zofer 4mg/iv
18/07/22
Platelets count reduce to 36000
19/07/22
Platelets count increased to 68000
Blood glucose level is normal .
20/07/22
Vitals stable.
Hypoglycaemia resolved.
21/7/22
Vitals stable
Hypoglycaemia resolved.
22/7/22
Vitals stable
Hypoglycaemia resolved.
Ready for discharge.
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