dac
47 year old male came to OPD with C/O Fatigue and unable to walk
- C/O generalised weakness since 1 month
- C/O burning sensation and tingling sensation present all over the body , relieves after taking alcohol
- Patient initially came for DAC Admission where they referred to gm opd I/V/O uncontrolled sugars and fatigue and unable to walk
- Patient Consumes alcohol daily in 4 episodes
5AM-6AM :- 180ml whiskey
11AM - 1PM:- 180ml whiskey
2PM- 3PM:- 180ml whiskey
6-7PM:- 180 ml whiskey
- C/O nausea and vomiting ( 2 episodes ) since yesterday morning
- Patient is unable to eat and also cannot remember anything when he is intoxicated
Hopi:-
Patient was apparently assymptomatic 3 years back then he was brought to our hospital for DAC ADMISSION , where he was counselled for 3 months and he stopped drinking for 3 years .
- Patient started drinking again from one month and from then on he has generalised weakness since 1 month and also fatigue and is unable to walk properly since 1 month
Past Illness:-
K/C/O HTN for 3 years ( On irregular medication :- Uses Metoprolol 25mg)
K/C/O DM for 5 years ( On irregular medication :- Uses glimi m2)
- takes medicines irregularly as he forgets to take medicine during intoxication
- N/K/C/O TB, Asthma , Epilepsy , Thyroid
Personal History:-
Diet :- mixed
Appetite :- lost
Bowel and bladder :- Regular
Addictions :-
-Chronic alcoholic since 20 years
Family History:- Not significant
O/E:-
Pt is Conscious , coherent , cooperative , oriented to time , place , person
NO Pallor , Icterus, Clubbing , Odema , Cyanosis , Lymphadenopathy
VITALS:-
Temp:- 98.1
PR:- 100/Min
RR:- 18cpm
BP:- 120/80mmhg
SPO2:-98%
CVS :- S1S2 heard , No murmurs
CNS :- INTACT
RS:- BAE +
P/A:- Soft , Non tender
RBS :- 297mg/dl
Diagnosis :-
Uncontrolled sugars under evaluation
Treatment plan:-
- GRBS Monitoring 7th hrly
- Tab GLIMI M2 PO/OD
- Awaiting FBS , PLBS, HBA1C Reports
FBS - 73mg/dl
