General medicine case 03 Sai Tarun 16-06-22

 GENERAL MEDICINE CASE (16-06-22)


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 5th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

DATE OF ADMISSION - 15/06/22

Introduction

- Patient came to psychiatry opd with chief complaints of tobacco dependence,sleep depriveness and erectile dysfunction.

HISTORY OF PRESENT ILLNESS

-Patient was chewing tobacco since 5 years.
- Patient went to vijayawada to a hospital 1mnth back and using the medicines.
-Currently chews 2 packets of tobacco/day.

HISTORY OF PAST ILLNESS 

•NO H/O fever, pain abdomen, vomitngs, abdomen distension, pedal edema.
-H/O 2suicide attempts in the past.
-C/O low mood and tobacco cravings.

PERSONAL HISTORY

•Mixed diet

  Appetite Normal

•Sleep adequate

•Bowel and Bladder movements regular.

TREATMENT HISTORY 

 • Not k/c/o diabetes, HT, CAD , asthma, TB.

•NO H/O chemo /radiation , blood transfusion.

•NO H/O previous surgeries.

- k/c/o Hypothyroidism since 2years and on regular medication.

FAMILY HISTORY 

• Not significant.


GENERAL EXAMINATION

CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - scaphoid

•No Tenderness

•No palpable mass

•No free fluid

•Spleen and liver not palpable

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

CEREBRAL SIGNS

•


INVESTIGATIONS 


PROVISIONAL DIAGNOSIS

-BPAD With Psychotic symptoms
- Tobacco dependence syndrome.

TREATMENT 






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