53 year old male patient complains of vomitings

 

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Date of admission-28th October 

A 53 year old male patient farmer by occupation came to the Casuality with chief complaints of vomitings since 1day

History of present illness 

Daily routine of the patient:

Patient wokes up at 6am in the morning,have his tea,goes to the field and do the farm work returns home and have his breakfast (rice) at 9am.He is a MPTC member and village head who solves public issues.So,he goes to the town and returns home in the evening and have his dinner at 8pm(skips his lunch daily).

Patient was apparently asymptomatic one day back.On the day before his admission into the hospital he attended a wedding,there he had non-veg along with alcohol and on the way to his home he had vomitings.Vomitings:5-6 episodes(first two episodes food as content and next 4episodes watery in consistency)bilious,projectile type.He then went into a state of dehydration and developed seizures.

He also complaints of stomach pain after taking food occasionally since many years.

No history of diarrhoea.

History of past illness 

11months back he had tingling and numbness in the head so he went to hyderabad and CT was done showing  lacunar infarcts in right thalamus which later reduced spontaneously. He is a known case of Diabetes Mellitus since 10years and hypertension since 5years.

Personal history 

Apetite -Normal

Diet -Mixed

Sleep -adequate

Chronic alcoholism since 5years(180ml-daily)

No history of smoking 

Family history 

Patient father was known case of DM and hypertension 

Treatment history 

He was on medication for DM and hypertension 

General Examination 

Patient was conscious ,coherent ,cooperative well oriented to time and place .

No pallor ,icterus ,clubbing ,cyanosis and no generalised lymphadenopathy 

VITALS

Temperature-afebrile 

Bp -140/70 mm hg

Respiration rate-26 cycles/min

Pulse rate-110 beats/min

Systemic Examination 

CVS:

No thrills

Heart sounds -S1 S2heard

No cardiac murmurs 

RESPIRATORY SYSTEM 

Dyspnea -No 

Wheeze-No 

Position of trachea -Central

Breath sounds -vesicular 

ABDOMEN 

Shape of abdomen-obese

No tenderness

No palpable mass

Hernial orifices-normal

No free fluid

No bruits 

Liver -Not palpable

Spleen -Not palpable

Bowel sounds -yes 

CENTRAL NERVOUS 

Level of consciousness -drowsy 1arousable

Speech -incoherent

Neck stiffness-No 

Kernings sign -No 

INVESTIGATIONS

Hb -17.3

TLC -10,900

Platelet -1.99

CUE :

Albumin +

Sugar++++

Pus cells - 3.4

Epithelial cells 2-3

FBS 214mg/dl

Urea -3.1

Creatinine-1.1

Na+ 135

K+ 3.5

Cl- 91

Serology -negative 

LFT 

Tb -1.60

Db-0.42

SGOT -16

SGPT -11

ALP-121

Tp-6.4

Albumin -3.9

A/G  ratio -1.66

TPR graph sheet

Ultrasound report

Provisional diagnosis

Seizures   

Treatment

1.1 ampoule thiamine in 100 ml ns

2.inj.Levetiracetam 500mg in 100ml ns

3.inj.pantop 40mg IV OD

4.inj.zofer 4mg IV

5.inj.Lorazepam 2cc IV sos

6.inj.neomol 1gm IV sos

7.tab dolo 650mg