Skip to main content

18

 Case History and Clinical Findings

17 YEAR OLD MALE WITH C/O ALTERED SENSORIUM SINCE 7:30 PM ON 8/8/23

C/O 2-3 EPISODES OF VOMITING SINCE 7:30PM

PATIENT WAS APPARENTLY ASYMPTOMATIC TILL TODAY MORNING

PATIENT HAD CONSUMED ALCOHOL (5 BEERS) AND PATIENT WAS ALTERED SENSORIUM

SINCE 7:30 PM IN THE NIGHT

PAST HISTORY:

N/K/C/O DM-II,HTN,CVA,CAD,TB,ASTHMA,EPILEPSY

GENERAL EXAMINATION

PATIENT WAS UNCONCIOUS AT PRESENTATION.

GCS SCORE E1V1M4

NO PALLOR,ICTERUS,CYANOSIS,LYMPHADENOPATHY,CLUBBING,PEDAL EDEMA

VITALS:

TEMP:AFEBRILE

PR : 96 BPM RR 18 CPM

BP 60/40 MM HG

SPO2 99

GRBS 119 MG/DL

PSYCHIATRY OPINION WAS TAKEN AND PATIENT IS COUNSELLED AND PSYCHOTHERAPY

IS DONE.

AND HARMFUL EFFECTS OF ALCOHOL IS EXPLAINED

Investigation

ABG

PH 7.297

PCO2 40.5

PO2 113

HCO3 19.2

RFT

UREA 19

CREATININE 0.8

URIC ACID 6.8

NA 132

K 3.3

CL 102

CA 9.8

HEMOGRAM

HB 13.9

TLC 14300

N/L/E/M/B 86/10/1/3/O

PCV 41.1

MCV 75.3

MCH 25.6

MCHC 33.9

RBC 5.45

PLT 2.73

FBS 95

Diagnosis ALTERED SENSORIUM SECONDARY TO ALCOHOL INTOXICATION (RESOLVED)

Treatment Given(Enter only Generic Name)

1.IV FLUIDS NS@ 100 ML

2.INJ. THIAMINE 800 MG IN 500 ML NS IV STAT

3.TAB. THIAMINE 100 MG PO/BD

Advice at Discharge

TAB. THIAMINE 100 MG PO/BD X 10 DAYS

COMPLETE ABSTINANCE FROM ALCOHOL

Comments

Post a Comment

Popular posts from this blog

A case of a 78 yr old female with altered sensorium

My patient is a 78 year old  female housewife hailing from a rural district in south india. She presented to us with chief complaints of : Patient was brought to casuality on 23/11/22 at 4:00 am early  in the morning with complaints of loose stools since 5 days and pain as mentioned by the atttender as she was screaming and restless with altered sensorium. History of presenting illness : The patient was apparently asymptomatic 5 days ago. She passed loose stools- watery in consistency, foul smelling and blood tinged on consuming kaya churnam (an ayurvedic powder) , went to RMP nearby and was given medication,  even upon which loose stools didnot stop . The attender mentions she became weak and then on 23rd nov, apparently after eating curd rice ,  when patient slept , suddenly in the middle of night patient was screaming due to pain  and could not talk anything, as mentioned by the attender. She was then bought to casuality. History of past illness: The patient'...
Post a Comment
Read more

24

 Case History and Clinical Findings 43 YEAR OLD FEMALE PATIENT CAME WITH COMPLAINTS OF FEVER SINCE 1 WEEK, VOMITINGS AND LOOSE STOOLS SINCE 4 DAYS INVOLUNTARY MOVEMENTSOF BOTH UPPER LIMBS AND LOWER LIMBS SINCE 1 DASY HOPI: PATIENT WAS APPARENTL ASYMPTOMATIC 1WEEK BACK, THEN SHE DEVELOPED FEVER OF LOW GRADE INTERMITTENT, RELIEVED ON MEDICATION NOT ASSOCIATED WITH CHILLS AND RIGOR, BURNING MICTURITION, COUGH AND COLD PATIENT HAD VOMITINGS WHICH ARE BILIOUS, NON PROJECTILE, NON BLOOS TINGED, FILLED WITH FOOD PARTICLES(2-3 TIMES PER DAY)     C/O LOOSE STOOLS LOW VOLUME, WATERY CONSISTENCY, NON MCOPURUENT, NON BLOOD TINGED, NO H/O OUTSIDE FOOD CONSUMPTION PATIENT HAD 3 EPISODES OF INVOLUNTARY MOVEMENTS 9RIGIDITY OF BOTH UPPER LIMBS AD LOWER LIMBS) ASSOCIATED WITH UPROLLING OF EYES, INVOLUNTARY MICTURITION, TONGUE BITE AND IS IN POST ICTAL CONFUSION/IRRITABLE SINCE THEN PAST HISTORY: K/C/O HTN SINCE 3 MONTHS(ON IRREGULAR MEDICATION OF UNKNOWN DRUGS) NOT A K/C/O DM, ASTHMA,...
Post a Comment
Read more

OSCE PREFINAL EXAM

 OSCE- PREFINALS DEC 2023: Case report :    I have tried to answer some of the questions regarding case discussion of our patient    1. How to clinically differentiate between coarse and fine crepitations ? Ans-  well, crepitations or crackles  are adventitious respiratory sounds which occur when an obstructed airway due to accumulated  secretions opens in inspiratory phase. The sudden opening of an obstructed airway causes an immediate re-equilibration of the pressures on both sides creating vibrations in the airway walls.  Fine crackles --  A).  having a short duration and a higher pitch,           Often, fine crackles are repetitive, originate          in the basal part of the lung, and not altered          by coughing. B) Coarse crackles  appear to be a longer                     durati...
Post a Comment
Read more