GM CASE STUDY

 Anvitha reddy 

Roll no .06

Introduction:
 45 yr old male came to gen medicine department with chief complaints of tremors, numbness in left lower and upper limb, dryness of mouth , loss of control , abdominal pain.
HISTORY OF PRESENT ILLNESS:
He was apparently asymptomatic 6 months back. He used to suffer from abdominal pain occassionally ( when he takes spicy food). He consulted doctor and took medicine. He got tremors on thursday morning 7:30 am as he did not consume alcohol. Tremors disappeared and became normal after consuming alcohol. He then took alcohol on friday and no symptoms seen. On saturday, he did not consume alcohol and he developed tremors, dryness of mouth, loss of control. He immediately went to RMP and took 2 injections. The symptoms did not diasappear. He then went to a private hospital. Ecg, RBS ,MRI,lipid profile tests were done and are completely normal. He was then reffered to KIMS hospital. 
Past illness:
No h/o DM HTN TB epilepsy asthma chromosomal abnormalities
No surgeries in the past
Personal history:
Married 
Diet: mixed
Appetite: normal
Bowel movements: normal
Bladder movements: normal
Sleep: normal
Addictions: alcoholic (since 25 years)
                    Non smoker
Family history:
Not k/c/o DM HTN TB asthma epilepsy
General examination:
No pallr
No cyanosis
No lymphadenopathy
No clubbing
No icterus
No oedema of feet
Temperature: 98.7F
Pulse rate: 74/min
Respiration rate: 18 per min
Bp: 110/70 mm Hg
Spo2 98%
Systemic examination:
CVS
No thrills 
S1S2 present
No murmurs
Respiratory examination:
No dysnopea
No wheezing
Position of trachea is central
Breath sounds are vesicular
Abdominal examination:
Shape of abdomen- scaphoid
No tenderness
No palpable mass
Hernial orifices are normal
No free fluid
No bruits
Liver not palpable
Spleen not palpable
Bowel sounds are present
CNS
llevel of consciousness- conscious
Speech normal
Signs of meningeal irritation:
    a) no neck stiffness
    b) no kernigs sign
Cranial nerves normal 
motor system normal
Sensory system normal
Glass gow scale normal
Reflexes
All are normal
Cerebral signs
Finger nose incordination - no
Kneel heel incordination - no
Provisional diagnosis: 
Alcohol dependent syndrome


Treatment:
Tab. LIBRIUM 25 mg
Tab. BENFOTHIAMINE 100mg
Tab. BACLOFEN 20 mg
Plan of care : conservative








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