GM CASE-2

Name : A.Anusri
Roll no :10
A 40 yr old patient came to the casuality with chief complaints of unconsciousness since 2 hrs
CHIEF COMPLAINTS:
unconsciousness since 2 hrs
History of present illness:
He took alcohol on 17/06/22 night(270 ml). He woke up next morning and went to collect toddy. Then went out to bring essentials. Atfer some time he had lunch and went to his shop. He then started behaving abnormally. He was taken to the RMP doctor. He gave hin B12 injection. He came home and slept for some time. His wife woke him up after some time for dinner. He was unable to wake up. Then he was brought to casuality.
History of past illness:
He had similar episode 1 yr back. He stopped taking alcohol after this episode. He was also diagnosed with HTN 1yr back. He took medicine for 2 months and then stopped taking after the advice of doctor. 
Not k/c/o diabetes , TB , asthma, epilepsy, chromosomal disorders, CAD
Personal history:
Married
Diet: mixed
Appetite: normal 
Bowel movements: normal
Bladder.movements: normal
Sleep : normal
Addictions: nonalcoholic since 1 yr (after the episode)
                     Non smoker
Family history:
His mother is diabetic and hypertensive patient
General examination:
Moderately built 
Conscious
Coherent
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
No clubbing
Vitals: temperature : 98.6 θF
            Pulse rate: 84
            BP : 140/100 mm Hg
            Respiratory rate: 18 cpm
            Spo2 96%
            GRBS : 116mg/dl

Systemic examination:
Cvs: no thrills
        S1 S2 present 
        No murmurs
Respiratory system:
       No dysnopea
       No wheeze
       Position of trachea is central
       Breath sounds - vesicular
       No adventitious sounds
Abdomen 
     Shape of abdomen- obese
     No tenderness
     No palpable mass
    Hernial orifices - normal
    No free fluid
    No bruits
    Spleen not palpable
    Liver not palpable
    Bowel sounds - yes
CNS 
 Level of consciousness - stupurous
 Speech - no response
 Signs of meningeal irritation 
      a) neck stiffness - no
      b) kernigs sign - no
Gallcow scale- E2 V1 M4
Provisional diagnosis:
Hypoglycemia secondary to alcohol intoxication
Treatment:
Inj THIAMINE 1amp in 100 ml NS
GRBS 6 th hrly
Monitor vitals
INVESTIGATIONS:
Haemogram:
Hb 12.6
TLC 4000
  N 35
  L 60
MCV 104.6
RDW 15.0
PLT 1.2
APTT 36s
PT 19s
INR 1.4
RBS 104 mg/dl
LFT
TB 1.68
DB 0.72
AST 78
ALT 57
ALP 144
Tp 6.2
Alb 3.8
RFT
urea 10
Cr 0.8
Uric acid 8.9
Ca+2. 9.4
Na+ 134
K+ 3.9
Cl- 102
ECG:

Ultrasound report :






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