GM CASE -2

March 6, 2023


GM CASE -2

CASE SCENARIO

Hi, I am E.Sushma sahithi, 3rd BDS student. This is an online eblog book to discuss our patients health data taking after his consent. This also reflects my patient centered online learning portfolio.

                   CASE HISTORY
Patient details : 
A 37 years old male , resident of suryapet works as a jr. assistant in social welfare association presented with 
Chief complaint: 
Patient was admitted in the hospital to get rid of alcohol and tobacco addiction.
History of present illness :
Patient was apparently asymptomatic 16 years ago and he's been consuming alcohol & tobacco from 2008 . Patient developed few symptoms after the sudden stoppage of alcohol
Fever ( high grade, intermittent) with chills from 8 days 
Vomittings( thick consistency,white color) more than 5 from 8 days 
Loose stools, from 5 days 
Cold ,cough from 7 days 

Aggrevating factors: epigastric pain while standing & walking
Relieving factors : relieved on medication
History of past illness : 
Patient was diagnosed with Type 2 Diabetes mellitus 6 months ago & took medication ( gemer1) for 3 days then discontinued. He started this medication again 1 week. 
No hypertension
No thyroid 
Family history: 
None of their family members have diabetes and any other diseases.
Personal history:
He is a jr. asst. in the social welfare society and married . He's a alcohol and tobacco addict, he observed that he had abdominal and epigastric pain so he stopped and wanted to decrease alcohol dependence. 
Diet        :  mixed 
Appetite:  normal
sleep      : normal 
Bowels.  : loose stools
Micturation: normal 
Addictions: Takes acohol 15-16 units per day and tobacco in the form amber 1 packet per day from 16 years , lately took alcohol occasionally and he stopped to get clean . 

General examination:
Moderate built/ well nourished
Conscious and cooperative 
Pallor- no
Icterus-no
Cyanosis -no
Clubbing - no
Jaundice-no
Edema-no
Lymphoedenopathy -no

Vitals : 
Temperature - 99.2°F 
Pulse rate- 98 bpm 
B.P-110/70
GRBS - 99md/dl 
Provisional diagnosis:
Fatty liver
Investigations:
Definitive diagnosis: 
Grade 2 fatty liver 
Treatment: 
Questions : 
1.Can we also call this as " withdrawal syndrome" as he stopped alcohol suddenly? 







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