27 year old male patient with chief complaints of Sob and vomiting

 27 year old male patient with chief complaints of Sob and vomiting

History of present illness -

Patient is a resident of iskilla , farmer by occupation he mainly does sowing rice and labourer work .patient was apparently asymptomatic on Saturday (12-2-2022) when he came home after consuming toddy around 90-180ml and complained of back ache to his mother later few hours in he had 5-6 episodes of loose stools and asked his mother for some food .He ate some rice and curry and asked for some milk. His mother gave him few drops milk while he layed in supine position, later at around 3am he had two episodes of vomiting, vomitus was milk like in colour, foamy and non projectile, later developed bilateral limb weakness and sob.Seeing his condition his family members called for an ambulance and carried him into it because he couldn’t walk by himself .They reached the hospital at around 9am .

Past history -

Not a known case of DM,HTN,TB,epilepsy ,thyroid abnormalities,no exposure to radiation 

3years ago 

In view of his addiction to alcohol his family members took him to a local deaddiction centre  in Nalgonda to get him treated for it.His hospital stay was around 23 days after which he relapsed 5-6 days later .

Personal history 

Patient is married(2017) ,father of two girls (3 and 4 years each ) 

Chronic consumer of alcohol since 6-7 years 

He consumes whiskey ,toddy of around 80-120ml regularly 

Chews tobacco (miraj) one pack everyday .

After consumption of alcohol there were few instances of dispute with family members at home .

Both wife and husband have to work in-order to be financially sustained .(wife is also a labourer ) .

Diet -mixed

Appetite-normal 

Sleep is adequate 

Bowel and bladder -regular until Saturday (12-2-2022)

No nsaid abuse 

No allergies 

General examination 

-patient is intubated

-Patient is conscious not coherent ,coperative .

  Well oriented time ,place and person .

Left eye is congested 

Pallor absent 

Icterus absent 

Cyanosis -absent 

Clubbing -absent 

Lymphadenopathy-absent 

Pedal oedema-absent

Vitals 

 

On admission 

TEMP-afebrile 

BP-150/90mmHg

HR-120bpm

RR-20cpm

SpO2- 98% on FiO2 80%

On 14-2-2022

TEMP-99.8F

BP-180/100mmHg

HR-118bpm

RR-29cpm

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM 

b/L respiratory crepts in all lung fields.

CNS EXAMINATION 

CVS EXAMINATION 

PER ABDOMEN 

soft, non tender, no organomegaly

INVESTIGATIONS

Ecg

Complete blood picture 

HB: 17.9

TLC: 4,000

N/L/E/M/B: 85/10/01/04/00

PCV: 53.4

MCV: 90.1

MCH: 30.2

MCHC:33.5

RBC:5.93

PT:2.06

RDW-CV :12.8

RDW-SD: 42.5

PS: NC/NC

Arterial blood gas 

(13-2-2022)

pH-7.233

PCO2- 48.5mmhg

HCO3-20 mm/lit

Anion gap -19.1mm/lit 

LFT

TB: 1.44

DB: 0.65

SGOT:40

SGOT:15

ALP: 169

TP:7.3

ALBUMIN:3.6

A/G: 1.36

RFT

BLOOD UREA : 21mg/dl

SERUM CREATININE: 0.8 mg/dl

SERUM ELECTROLYTES:

Ca : 9.6

Na+ : 144

K+: 4.0

Cl-: 100

Rbs : 125

Serum osmolality : 302.4

CUE

Albumin : 3+

Sugar : 2+

APPT -31 sec

PT-1.11sec

 

SEROLOGY -negative