45 year old male resident of Narketpalli came with a giddiness and shivering

 Hi, I am Tadaka Shivaram krishna , 3rd Sem Medical Student.This 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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”I've 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 a diagnosis and treatment plan.

CHIEF COMPLAINT 

Giddiness since 4 hrs 

Shivering since 1 hr 

Vomiting 1 episode  

HISTORY OF PRESENT ILLNESSES 

Patient was asymptomatic few hrs ago then develops sudden onset of giddiness  immediately after waking up from sleep shivering since one hr 

Vomitings 1 episode non bilious  non projectile  watery 

N/H/O  -  fever  ,  cough   ,  sob , loose stools

HISTORY OF PAST ILLNESS 

Pain in abdomen 

No relative  past history 

TREATMENT HISTORY 

Diabetes - no 

Hypertension - no 

CAD -  no 

Asthma - no 

Tuberculosis - no 

Blood transfusion - no 

Surgeries - no 

  

PERSONAL HISTORY 

Married 

Appetite - normal 

Mixed  diet 

Bowels - regular movement 

Micturition - normal 

Known allergies - none 

Habits / addictions - 

a )   Alcohol -  3 quarters per day , since 30 years 

b )  Tobacco - none 

c ) Drug use - none  

d )  betel nut - none 

Family history 

Diabetes - No 

Hypertension - No 

Heart disease - No 

Stroke - No 

Tuberculosis - No 

Asthma - No 

Siblings history - none 

PROBABLE DIAGNOSIS 

ALCOHOLIC LIVER DISEASE