Case of a 27 Year old male with SOB

CHIEF COMPLAINTS 

This is the case of a 27-year-old male who presented to the Casualty today morning with chief complaints of 

  • Shortness of Breath - since the morning 
  • 3-4 episodes of vomiting since last night
  • 4-5 episodes of loose stools  since last night 
HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic one day ago. 

Last night , the patient consumed two bottles of toddy(more than his usual amount - which is 1 bottle, the source of the toddy was different from the usual place) and had a meal with rice and curry, after which he went to sleep.
 
The patient had an episode of loose stools in his sleep and had 4-5 loose stools since then patient also had 3-4 episodes of vomiting (White)since last night.The patient also complained of lower back ache with these episodes of diarrhoea and vomitting. No one in his family other than him complained of diarrhoea or weakness. 

At 4 AM, the patient felt hungry and was given milk by the mother, after which he started complaining of shortness of breath. 

At 9 AM, the patient was brought to the casualty with severe shortness of breath.Accordig to the patient relatives, the patient was in a delirious state, there were no tremors , the patient was unable to stand up on his own and complained of weakness in his legs. 

HISTORY OF PAST ILLNESS and DRUG HISTORY 

The patient is not a known case of DM, TB, Asthma, HTN, CVA, CAD.

The patient has a history of administration of an injection for de-addiction from alcohol 3 years ago, the patient was admitted in the hospital for 23 days .He quit rehabilitation as his intake had reduced. 

FAMILY HISTORY 

No relevant family history.

PERSONAL HISTORY 

  • The patient has been married for 5 years he has 2 daughters. 
  • Diet - mixed 
  • Appetite- Normal 
  • Sleep- adequate 
  • Bowel movements- Complains of 4-5 episodes of loose stools since last night. 
  • Bladder movements- Normal. 
  • Addictions - The patient is a chronic alcoholic.  According to the attendee, the patient has been consuming alcohol every day from the past 15 years : about 1 bottle of toddy. He started drinking due to work stress, and got addicted to it. 
    • 3 years ago, the patient went to another hospital and was given an injection for the de-addiction from alcohol, after which, his consumption was reduced for a month, and increased again. 
    • He went to the hospital because he used to argue after intake of alcohol,so in order to control that he thought of rehabilitation. 
    • One day before admission the patent had 2 bottles of toddy (double his usual amount) . 
  • The patient chews tobacco- one pack a day. 
  • No history of smoking. 

VITALS- on admission 
 
Pulse rate- 120 bpm 
Respiratory rate - 40 breaths per minute 
BP- 190/90 mmHg
GRBS- 216 mg/dl 
SPo2-60 per cent 

INVESTIGATIONS -

ECG
  1. DAY 1- 9.24 AM 


  2. DAY 1 -11.58 AM 
  3. DAY 2 - 7.29 AM 


ABG 

1. DAY-1- 12.35 AM 

2. DAY 1- 6.27 PM 
3. DAY 2- 4.36 AM

4. DAY 2- 5.01 AM 





Serum Osmolality  - 302.4 

RBS- 125


LFT 
  • Total Bilirubin- 1.44
  • Direct Bilirubin -0.65
  • AST-40
  • ALT-15
  • Alkaline Phosphate -169
  • TP- 7.3
  • A/G=1.36
  • Albumin-3.6
RFT
  • Blood Urea- 21mg/dl
  • Serum Creatinine - 0.8mg/dl
  • Serum electrolytes 
    • Ca-9.6
    • Na-144
    • K-4.0
    • CL-100
HEMOGRAM
  • HB-17.9
  • TLC-4000
  • Neutrophils-85
  • Lymphocytes- 10
  • Eosinophils-1
  • Monocytes-4
  • Basophils -0
  • PCV- 53.4
  • MCV-90.1
  • MCH-30.2
  • MCHC-33.5
  • RBC-5.93
  • PT-2.06
  • RDW-CV-12.8
  • RDW-SD-42.5
  • Normocytic, Normochromic 

DAY -2 

Spot urine protein- 39
Spot urine Creatinine -123

APTT-31 seconds
PT-15 Seconds 

Complete Urine Examination - 
Albumin - 3+
Sugars- 2+
RBC crystal casts - Nil 





Chest Xray - 
DAY-1


DAY 2- 


Provisional Diagnosis - Type 1 Respiratory Failure Secondary to  Aspiration Pneumonia 

Treatment - 
  • Head end elevation 
  • RT feed - 100l free water 2nd Hourly, 50 ml milk 4th hourly 
  • IV-20 NS at 75ml/Hour 
  • INJ PIPTAZ 4.5gm IV-Stat
  • INJ PANTOP 40 mg IV OD
  • INJ ZOFER  4mg IV YID
  • Nebulations with mucomist 4th hourly 
  • ABG -4th hourly 
  • ECG - every 4 hours 
  • INJ-THIAMINE  

DAY 2-

VITALS 
  • BP- 180/100 MMHG
  • PR-110bpm
  • RR-22 cycles per minute 
  • FIO2-35 per cent 

  • The patient's consciousness improved
  • The patient showed spontaneous eye movements 
  • The patient had improved breathing 
  • Sedation was removed 


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