70 YEAR OLD MALE WITH ALTERED SENSORIUM

CHIEF COMPLAINTS :
- complain of vomiting at 4:00 p. m on 29/09/22
- complain of BREATHLESSNESS since then 
- complain of unresponsiveness @7:00 p. m on 28/09/22 

HOPI:
A 70 yeal old man was brought to the casuality with complaint of an episode of vomiting at 4:00 p.m on 28/09/22, which was non-projectile, non bilious, non blood stained with food particle as content. 
- After which from 7:00 p. m he started getting breathlessness associated with which was not associated with chest pain, palpitation, PND, orthopnoeaorthopnoea. 
- No history of fever / cough/ seizure like activity / cold / burning micturition / chest pain / abdominal pain / decreased urine output / head injury. 

PAST HISTORY 
- K/c/o HTN since 2 years and on treatment 
- k/c/o Asthma since 3 years and on treatment 
- no other comorbidities 

PERSONAL HISTORY :
Diet: mixed 
Appetite: normal
Bowel and bladder movement : regular 
Allergies : to dust 
Addiction :
Alcohol: regular since 50 yrs 
Tobacco: stopped 2 years baxk
No other addiction 
FAMILY HISTORY: Not significant 

GENERAL EXAMINATION:
Patient is C/C/C
No pallor 
No icterus 
No cyanosis 
No clubbing
No lymphadenopathy 
No edema
 VITALS:
Afebrile 
BP: 160/100mmHg 
PR: 73bpm
RR: 36cpm
Spo2 : 99 per cent at room air 
GRBS: 155mg/dL

SYSTEMIC EXAMINATION:
CVS: S1S2 +
RS: BAE+ , clear 
P/A: soft, non-tender 
CNS: 
 Level of consciousness: drowsy 
Speech : incoherent 
No meningeal irritation

CLINICAL IMAGES

INVESTIGATION:

ULTRASOUND
CT SCAN-PLAIN Report
2D ECHO REPORT 


DIAGNOSIS: ALCOHOL ABUSE                                WITH INTOXICATION

My Orientation around this case :
1. What might be the reason of his breathlessness? 
Ans. May be due to binge of alcohol intake

2. What are his precipitating factor for breathlessness? 
Ans. - H/o asthma since 3yrs 
        - allergy to dust 
        - binge alcohol intake 

3. What are his systemic examination finding? 
Ans. In Respiratory system examination, B/L rhochi present in Infra-axillary area. 

4. Why Inj. Thiamine is usually given to chroning alcoholic? 
Ans. To prevent Thiamine induced Wernick's Encephalopathy. 















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