17 years old male with altered sensorium and vomiting after binge of alcohol.

This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."
                                         " I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan "




Unit posting (Intern 2017)

Medical Ward 
GM II 
Dr Nikitha
Dr Haripriya
Dr Govardhini
Dr Stimita






17 years old male with altered sensorium and vomiting after alcohol intake.



CHIEF COMPLAINTS

17 years old male patient(school going student)was brought to casualty in unconscious state with a history of  alcohol intake.


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic till 6:30pm and then he developed altered sensorium and 2 episodes of vomiting(containing food )

The scenario was-

Patient was at home since morning.
➡️Around 11 am,
he took his meal containing rice, vegetable curry (the only meal he had yesterday according to his parents)
➡️Around 4:30 pm,
he went with his friends to celebrate his friend's birthday.They went to a park.
According to his friends he drank 5 bottles of beers in that birthday party.
➡️Around 6 pm,
 he called his parents and asked them to switch on the geyser as he wanted to take bath after reaching home.
➡️Around 6:30 pm,
he developed altered sensorium and had one episode of vomiting(non foul smelling,content as food particles) in the park.
➡️Around 7:30 pm,
his friends brought him to his home.After reaching home, he had another episode of vomiting (non foul smelling,content as food particles)
His parents were scared and brought him to hospital.


According to his parents, this was the first time he consumed alcohol.

At presentation-
GCS SCORE-E1V1M4
PR 96  bpm
RR 18cpm
BP 60/40 mmhg
SPO2 99%
GRBS 119mg/dl

GENERAL EXAMINATION 


Well informed consent is taken. Examined in a well lit room.

Patient is Unconscious.Oriented to person.

Thin built and moderately Nourished. 


Vitals 

Afebrile

BP 60/40mmhg

PR 96bpm

Respiratory rate 18 cpm


There is no pallor,icterus, clubbing, cyanosis or lympathadenopathy,Pedal Edema 







SYSTEMIC EXAMINATION 

Abdominal examination 

Soft, non tender.
Bowel sounds heard.



Cardiovascular system examination 

S1 and S2 heard , no added thrills and murmurs heard.




Respiratory system examination 

BAE +
Normal vesicular breath sounds heard 
No adventitious sounds
 
CNS EXAMINATION

GCS SCORE - E1V1M4

INVESTIGATION



PROVISIONAL DIAGNOSIS

Altered sensorium secondary to alcohol intoxication


TREATMENT
8/8/23
1.At presentation,BP was 60/40 mmg after giving 500ml of NS bolus, BP was 90/60mm hg
2.INJ.THIAMINE 800 mg in 500 ml NS  IV STAT 

9/98/23
TAB. THIAMINE 100 mg PO/BD 

Psychiatry opinion was taken on 9/8/23, patient is counselled and psychotherapy is done.
Harmful effects of alcohol is explained.



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