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