47/M CAME OPD C/O FATIGUE AND UNABLE TO WALK

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 



HISTORY OF PRESENTING ILLNESS - 

Patient was apparently asymptomatic 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 because of 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 moderately built and well nourished
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 with type 2 diabetes mellitus with alcohol dependence with Tobacco dependance 

Treatment plan:-
1)TAB. THIAMINE 2AMP IN 100ML BD
2) TAB GLIMI M2 PO /BD
3) TAB .LIBRIUM 25MG BD
4) TAB . BEN - XL PO / BD 
5) TAB. PAN -D PO/ OD 
6) TAB . METOPROLOL 25 MG PO/ OD 
7 ) GRBS 7 POINT PROFILE MONITORING
8) STRICT DIABETIC DIET

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