case 1 : A 41y old man with altered sensorium

 

A 41y old man with altered sensorium

September 02, 2020

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Here is a case i have seen :

 A 41yr old man  who is a farmer came with complaints of pain abdomen and vomitings since one day

Patient was apparently alright 2 days back later he had pain abdomen following an acute binge of alcohol(750ml of local liquor) in epigastric region, colicky type,non progressive, non radiating,Which got relieved on taking food

He had vomitings-2 episodes, non bilious,non projectile,contents being food particles

No H/o fever, loose stools, melena, abdominal distension, constipation, burning micturition, head trauma

PAST HISTORY:laprotomy done 10 yrs back for peptic ulcer perforation

Not a k/c/o HTN, DM, CAD, epilepsy,CKD

HABITS: He was on mixed diet, normal appetite, bowel n bladder regular

Chronic alocholic since 10-12 yrs-initially 350ml per day later 750ml local liquor every day

Toddy intake 1-2 bottles if liquor not available

Chronic smoker since 10 yrs Beedis—1pack/day

Cravings for alochol and tobacco chewing present

GENERAL EXAMINATION:

Pt is conscious, irritable and confused(GCS-13/15) moderately built and nourished

No Pallor,icterus, cyanosis, clubbing, lymphedenopathy, pedal edema

VITALS: febrile-100 degree celsius

                BP: 160/100mm hg

                Pulse:80bpm

                RR-28cpm

PER ABDOMEN- shape of abdomen-scaphoid 

 umbilicus - inverted , soft, tenderness +, no guarding , no rigidity,no organomegaly, bowel sounds heard

CVS-s1 s2 heard, no murmurs

RS- BAE clear, no added sounds

CNS- pt is agitated and confused and was restrained 

        Not co operative so could not perform cns examination and MMSE

INVESTIGATIONS:

      

3-09-2020

TREATMENT:

1 NBM till further orders

2 IV fluids

3 INJ PANTOP 40mg OD

4 INJ TRAMADOL 1 amp in 100ml NS BD

5 INJ THIAMINE 1 amp in 100ml NS TID 

6 INJ LOREZEPAM 4mg slow IV /6th hrly

7 INJ HALOPERIDOL 5mg im/sos

8 GRBS 6th hrly

9 BP/temp/PR 4th hrly

10 I/O charting

                    

PROVISIONAL DIAGNOSIS:?ACUTE PANCREATITIS 

                      ?  ALCOHOL    WITHDRAWAL SYNDROME

                                                 ? DELIRIUM TREMENS

                                 ?WERNICKE’S ENCEPHALOPATHY