58M generalised weakness

A 58yr old male C/O generalized weakness 

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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.

Chief complaints 

A 58yr old male was bought to the casuality with the complaints of generalized weakness and fatigue

History of presenting illness 

The pt was apparently asymptomatic 30yrs ago then he started drinking toddy 1bottle in evening after doing agriculture work.He continued drinking toddy for next 10 years. Later the pt shifted to drinking liquor half bottle initially almost 2-3 times a week. He then experienced sleep disturbances, sweating, palpitations, mild tremors if he stopped drinking for one day. Pt was currently drinking 500ml of liquor since past one month. Pt developed generalized weaknesses,easy fatigability, giddiness one week ago. Hence got admitted in pvt hospital in Miriyala guda. Pt developed hypotension and was in unresponsive state hence in emergency shifted to tertiary care kims hospital. Pt was having occasional irrelevant talk.

Not a K/C/O hypertension, diabetes, TB, epilepsy, thyroid,asthma

Personal history

Appetite: decreased

Sleep: irregular since five days 

Bowel and bladder: regular

Addictions: alcohol since 30yrs, smoking (5-6 bedis per day)

Family history

Not significant

General examination

Patient is examined in a well lit room after taking an informed consent. 

Patient is conscious and coherent. 

No signs of pallor, icterus, clubbing, cyanosis, generalized lymphadenopathy, pedal edema

Vitals

Temperature: 98.6 farenheit

Pulse: 106 per minute

RR : 18 per minute

BP: 80/40

SPO2: 98%

Systemic examination

CVS: S1 S2 heard, no murmurs

RS: BLAE( benign lymphangioendothelioma) present

CNS: No focal deficits

P/A : soft, non tender

Investigations

 

Provisional diagnosis

Hypovolemic shock