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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

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