46M DIABETES 6 YEARS INSULIN,WITH PANCREATITIS,ALCOHOL DEPENDANCE SYNDROME AND TOBACCO DEPENDANCE SYNDROME

HIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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   

[28/07, 6:10 pm] ~ govardhini reddy: A 43 yr old male agricultural labourer by occupation from chityala came with chief complaints of spasm of fingers of upper limbs with tremors since 3 days,generalized weakness and excessive sweating with decreased pitch of voice since 3 days

lived with his father mother and brother,studied upto 10th standard and due to lack of studies he discontinued studying further.Since then he use to rare domestic cattle and do farming and go to gym and doing fine . At around 20years age due to peer pressure and curiosity he had alcohol and started smoking and since then he drank occasionally and smokes around 10 cigarettes/day .His father expired in 2004 for which he felt depressed.In 2005 he started to have neck and shoulder pain for which surgery was done in 2007 and in 2007 at the age of 27 years he got married (consaguinous) and had 2 children.

 His wife used to help him in agriculture work.His addiction for consumption of alcohol increased after 7 years of marriage.In 2008 patient had severe abdominal pain and diagnosed as having pancreatitis for which surgery was done.

After 5 years of that event patient started having generalized weakness and increased sweating for which he went to hospital and was diagnosed of having diabetes for which he started on insulin.He stopped consulting doctor for followup and continued on insulin since then (Inj.Hai 10U-10U-10U sc/tid).And remained asymptomatic since then.He got separated from joint family and 4 years ago he applied home loan and brought a house where he lived with his wife,daughter and son and doing fine since then.Since 1 year patient noticed that he was having tremors while doing work(left upper limb>right upper limb) the intensity of tremors and generalized weakness increased after every episode of alcohol intake and decreased on their own .In 2023 january patient felt more stressful due to agriculture work,spouse health issues and financial burden.In the late half of january 2023 patient developed generalized weakness,decreased sleep and low grade fever for which he got treated by a local RMP and had an episode of involuntary movements(?GTCS) and got admitted into an hospital.He used medication for 2 months and stopped without physicians advice.He remained asymptomatic till june 2023.In june 2023 his wife had surgery for hernia and remained bed ridden for which he felt stressful.He lost the followup and stopped using medication and started binge drinking since 10 days.

[28/07, 6:11 pm] ~ govardhini reddy: Clinical complexity 

Biological:

• Chief complaints of spasm of fingers in upper limbs with tremors, generalized weakness, excessive sweating, and decreased pitch of voice.

• History of neck and shoulder pain, leading to surgery in 2007.

• Diagnosis of pancreatitis in 2008, which required surgery.

• Diagnosis of diabetes and initiation of insulin therapy, but poor follow-up with healthcare.

Psychological:

• Experience of depression following the demise of his father in 2004.

• Increased alcohol consumption as a coping mechanism due to peer pressure and curiosity.

• Stress and emotional strain due to spouse health issues and financial burden.

Social:

• Limited educational background, discontinuing studies after 10th standard.

• Agricultural laborer by occupation, engaged in farming and rearing domestic cattle.

• Lives with his wife, daughter, and son in a house he acquired through a home loan.

• Consanguineous marriage and has two children.

• Financial stress due to home loan and family responsibilities.

• Increased alcohol consumption and smoking as social and coping habits.

• Recent stress due to wife’s surgery, leading to binge drinking.

Inspectory findings confirmed

No tenderness, local rise of temperature

Normal expansion of chest on both sides in all areas

Position of trachea: Central

Vocal fremitus: resonant note felt

PERCUSSION:

Resonant note heard over all areas

AUSCULTATION:

BAE positive

Vocal resonance: resonant in all areas

CNS EXAMINATION:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES : normal 

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee reflex elicited and b/L ankle reflexes cannot be elicited .

Tremors - present . 

Investigations:

Hemogram :

Hb -14.1 %

T.c -11,400

M-46

L-44

E-01

M-09

B-0

Pcv-40.4

MCH -30.3

MCHC-34.9

RDW-CV -14.3

Plt-3.65 lakh 

Hba1c: 7.2%

FBS :140 mg/dl 

RFT 

UREA-16

Creatinine-0.7

Uric acid -2.5 

Sodium -137

Potassium -4.1 

Chloride -100

CUE :

Albumin - nil 

Sugars - ++++

Pus cells -2 -3 

Cast - nil 

LFT 

TB-1.09

DB-0.39 

SGOT - 18 

SGPT - 10 

ALP - 132 

TP - 5.9 

Alb - 3.98 

A/g - 2.07 

2d echo : 

No MR AR TR 

NO RWMA 

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION 

NO PAH/PE 

Treatment:

Tab thiamine 100 mg po/bd 

Inj HAI s/c TID according to GRBS 

Inj NPH s/c according to GRBS