general Medicine elog 4

21-06-22
Hi ,I am Swetha , 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.
Chief complaints :  A 37 years old male patient toddy tree climber by occupation resident of Nalgonda district brought to causuality with history of unconscious state since 2 hrs 
HOPI:
The patient was regular alcoholic,after his routine work as toddy tree climber, around 11am had lunch and went for bringing daily essential and sat in shop aftersome time he started giving money to the people who come to shop it was identified by his wife and  around 4 pm he was feeling uneasy he was shown to RMP doctor and give vit B 12 supplement.and advised for sleep and later on had fruit( guava)after an hour when his wife was weaking him up for dinner he was not responding brought to hospital. 
Past history : alcoholic since 20 years .
Varicocele 1 yrs back 
Personal history: normal appetite,non vegetarian diet , normal micturition,,no known allergies ,had  no habit of using drug
Family history: no history of diabetes,HTN, heart disease,stroke ,cancer,TB , asthma
General examination:
No pallor , icterus,cyanosis, lymphadenopathy, clubbing of fingers and toes, oedema of feet 
Temp: 98.6  C/F 
P.R : 82/min 
RR: 24/min
B.P: 140/90mmhg 
Sp02: 96%
GRBS: 116 mg %
Systemic examination:
CNS: no thrills,
Cardiac sounds present
No cradiac murmur
Respiratory system: no dyspnea, wheeze
Position of trachea central 
Vesicular breath sounds
Abdomen: obese,no tenderness  not palpable mass .not palpable liver, spleen
CNS  : unconscious ,
Speech: no response
Investigation:
Hemogram,CUE,LFT,RFT, ECG ,USG abdomen

Diagnosis: hypoglycemia , alcohol intoxication.
Treatment :

Inj.4gm thiamine in 500 ml na / iv/@75ml/ hr 
Inj: thiamine 100mg in100 ml vs/iv/told
Inj: pan 40 mg /iv/ od
BP checking 6 th hourly

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