A 30 YEAR OLD MALE FARMER WITH CHIEF COMPLAINTS OF DYSPNOEA AND NAUSEA

 THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

A 30 year old male farmer by occupation came to casuality on 13/2/22 (sunday) with chief complaints of dyspnoea since 2hrs and nausea since 2hrs

HOPI:

patient is father of 2 girls and is an alcoholic since past 5 to 6 yrs .He was apparently asymptomatic since 12/2/22 then he went to a party where he ate biryani and then consumed toddy and then he developed generalized weakness and then two episodes of loose stools.

At 4am in the morning patient was hungry ,so he was given milk when he was in supine position by his attender(mother) following few seconds he started coughing and was dyspneic and also patient complained of nausea and became tachypneic

past history:

h/o intake of herbal medication for one day for alcohol dependance syndrome

not a known case of DM,HTN,TB,epilepsy,CAD

personal history:

diet:mixed

appetite: normal

bowel and bladder moments:normal

addictions:he is alcoholic since 6 yrss,he chews tobacco 1 pack per day

Family history;

no significant family history

general examination:

patient is conscious,coherent,cooperative,no signs of pallor,icterus,clubbing,no lymphadenopathy,no edema

vitals:

temp:98 f

bp:170/90 mmhg

pulse rate:99bpm

respiratory rate:40 cpm

spo2:60%

grbs:146

systemic examination:

13/2/22

cvs: s1 and s2 heard ,no murmurs

respiratory system:bilateral respiratory crepts in all lung fields

per abdomen: soft,non tender, no organomegaly

cns:NAD

17/2/22

CVS:S1 and s2 heard,no  murmurs

respiratory system:normal sounds heard

per abdomen: soft, non tender,no organomegaly

cns:NAD


Investigations:

Hemogram:

HB:17.9

TLC:4000

PCV:53.4

MCV:90.1

MCH:30.2

MCHC:33.5

RBC:5.93

RFT:

BLOOD UREA :21mg/dl

SERUM CREATININE:0.8mg/dl

SERUM ELECTROLYTES:

ca:9.6

na:144

k:4.0

cl:100

LFT:

TB:1.44

DB:0.65

AST:40

ALT:15

ALP:169

TP:7.3

ALBUMIN:3.6

A/G:1.36

SERUM OSMOLALITY:302.4

COMPLETE URINE EXAMINATION:

ALBUMIN:3+

SUGAR:2+

ECG:



CHEST X-RAY:


                                    BEFORE INTUBATION


                                    AFTER INTUBATION
abg :14/2/22


TREATMENT:

HEAD END ELEVATION

INJ.PIPTAZ 2.25gm/iv/6th hrly

NEBULIZATIONS WITH MUCOMIST 4TH HOURLY AND BUDECORT 6TH HOURLY

CHEST PHYSIOTHERAPY 12TH HOURLY

INJ THIAMINE 1 AMP IN 100ML NS IV/TID

MONITOR VITALS HOURLY 

FREQUENT SUCTIONING OF ORAL AND NASAL SECRETIONS

Clinical pictures:






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