05 Vignesh

CASE SCENARIO 

A 63yr old male patient came to opd with chief complaints of Sleep disturbances and Low mood since 1 year

History of present illness

Pt developed skin lesions on ankle following which spread to Lower limb..pt was diagnosed with psoriasis 1 yr back
Due to spread of lesions to most of the body pt liked to be in home rather going out and and he liked to be alone since then he had sleep disturbances and Low mood..

History of past illness

Chronic plaque psoriasis since 1 yr

N/k/c/o -htn,dm

Personal history 

Pt drinks alcohol since 35 yrs 2 to 6 units
And smokes since 35 yrs
Mixed diet

Treatment History 

Pt is on Treatment for psoriasis 

GENERAL EXMINATION:

Patient is conscious, coherent

Absence of:pallor
                      icterus
                      clubbing
                      cyanosis
                      pedal edema
                      lymphadenopathy.

VITALS: 

Temperature: 98 F

Pulse rate: 85 beats per min

Respiratory rate: 16 cycles per min 

BP: 120/70mm Hg

SpO2: 98% @ Room air 

GRBS: 172mg% 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1, S2 heard

No thrills, No murmurs

RESPIRATORY SYSTEM:

Normal vesicular breath sounds

Position of trachea is central

Dyspnea is absent 

No wheeze

EXAMINATION OF ABDOMEN:

Shape- scaphoid

No tenderness

No palpable pass

Normal hernial orifices 

No free fluid

No Bruits

Liver is not palpable

spleen is not palpable

Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

Patient is conscious 

Speech is normal 

No focal neurological defect

All reflexes were present 

Absence of cerebral signs

INVESTIGATIONS 

                     







DIAGNOSIS 

■ALCOHOL DEPENDENCE SYNDROME 

■TOBACCO DEPENDENCE SYNDROME 

■ADJUSTMENT DISORDER DUE TO 
   PHYSICAL ILLNESS 




Treatment 

Tab.Lorazepam 2mg

Tab.Benfothiamine 100mg

Tab.Sertraline 25mg

Liquid Paraffin

Tab.Atorvastatin 20mg 

Tab.Drotin  P SOS

Syp.Citralka 10ml

Tab.Atarax 25mg

Fudic cream l/a

Venusia cream l/a









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