A 60 yr old female with alcohol dependence syndrome assosiated with viral pyrexia and acallculous cholecystitis
A 60-year-old female patient who is a farmer by occupation and a resident of nakrekal came to the casualty with the cheif complaints of fever since 15 days and shivering, altered sensorium and incoherent talk since 6 day and pain abdomen since 7 days.
HISTORY OF PRESENT ILLNESS :
patient was apparently asymptomatic 15 days back, then she developed fever which was insidious in onset and intermittent in Nature, with chills and rigor
The patient developed pain in epigastric region 7 days back which was sudden in onset, non progressive and non radiating.
There is history of 1 episode of vomiting, which was non bilious, non foul Smelling, non projectile and food as its contents.
After onset of fever she was taken to a nearby hospital, over there the doctors referred the patient to our hospital and over here she was admitted for 6 to 7 hrs and then got discharged.
On the next day she started having altered sensorium, incoherent talk and tremors so she was rushed to a nearby hospital and again the doctors referred the patient to our hospital.
No history of shortness of breath
PAST HISTORY:
N/K/C/O of DM,HTN,Asthma,TB,Epilepsy,CAD.
PERSONAL HISTORY:
Diet : Mixed
Appetite : Decreased
Sleep : Disturbed
Bowel and Bladder moments :Regular
Addictions:chronic alcoholic since 30yrs
Betelnut chewing since 30yrs
FAMILY HISTORY:
Not significant.
GENERAL PHYSICAL EXAMINATION:
Patient is conscious ,incoherent and cooperative and not well oriented to time, place and person.
moderately built and nourished.
Pallor-absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Edema-absent
Vitals:
Temperature - 99.5*c
PR :- 75bpm
RR :-22cpm
BP :- 110/80mm Hg
SPO2 :- 98%
GRBS :-106mg/dl
SYSTEMIC EXAMINATION:
CVS-S1S2 heard no murmurs
RS-BAE+
CNS-NFND
P/A-soft, tenderness present over epigastric region.
INVESTIGATIONS:
Dengue Elisa -
LFT - on 21 aug
CBP -
Blood urea -
ABG -
Serum creatinine - on 21 aug
Serum electrolytes -
Serum amylase -
Lipase -
USG -
ECG -
PROVISIONAL DIAGNOSIS:
Alcohol dependence syndrome associated with Viral pyrexia and Acallculous cholecystitis.
TREATMENT:
IV fluids-NS,RL,DNS
IV monncef 1mg/iv/BD
Inj Rantac 50mg/iv/OD
Inj PMC 2mg/iv/sos if temp is >102*F
Inh Zofer 4mg/iv/sos
Inj Thiamine 200mg in 100ml NS/if/BD
Tab Prednisolone 10mg/po/OD
Tab Olanzepine(mouth dissolving)2.5mg x 2days.
Comments
Post a Comment