CASE DISCUSSIONS

45YR old male, real-estate business man, came to OPD with cheif complaints of
1.VOMITINGS , 2-3 episodes per day since 1week.
2. HEMETEMESIS , 2episodes , 10-15ml , 1week back.
3. MELENA since 2days.
No H/O fever, pain abdomen, diarrhoea.

Not a K/C/O DM, ASTHMA,TB.

PAST HISTORY:
2yrs back, when he was at home around 
11-12pm , he had INVOLUNTARY MOVEMENTS OF LEFT UL,LL
   DROOLING+
   DEVIATION OF MOUTH+
   ROLLING OF EYE BALLS +
then he fell down.
INVOLUNTARY MOVEMENTS LASTED FOR ABOUT 5MIN.
He was in POST ICTERAL CONFUSION STATE FOR ABOUT HALF HOUR.
Then he was taken to hospital, where his BP WAS HIGH.
started on ANTI HYPERTENSIVES and 
ANTI EPILEPTICS.
ANTI HYPERTENSIVE - NOT DOCUMENTED.
ANTI EPILEPTICS:
    LEVIPIL 500MG /BD
He continued to use these medications for almost one and half yr , and stopped using anti epileptic medication 1mon back.

Now these acute complaints since 1week.
LAST BINGE OF ALCOHOL 3DAYS BACK.

no significant family history

PERSONAL HISTORY:
Takes mixed diet
Appetite is normal
Bowel and bladder movements are normal
No malnutrition
No dehydration.
ADDICTIONS: 700ml of whiskey daily since 20yrs.
No H/O smoking.

O/E:
PT is C/C/C
no pallor, icterus,cyanosis, clubbing, lymphadenopathy, edema
VITALS:
TEMP- AFEBRILE
PR:82BPM
BP:130/80MMHG
RR: 18CPM
SPO2:99%

CVS: S1S2+
RS:BAE+
PER ABDOMEN: SOFT

CNS: 
POWER 5/5 
REFLEXES 2+ 
NO ANY TINGLING OR NUMBNESS.
IMAGING NOT DONE.


INVESTIGATIONS:.

HEMOGRAM:
HB: 15.8
TC: 5000
PL: 42000

SERUM CREATININE: 0.6

SERUM ELECTROLYTES:
Na: 13.6
K: 3.6
Cl: 0.6

CHEST XRAY:
USG ABDOMEN :
ECG:

PROVISIONAL DIAGNOSIS:.
VIRAL PYREXIA with THROMBOCYTOPENIA.
ALCOHOLIC GASTRTIS.
K/C/O HYPERTENSION AND SEIZURES 
 (? ALCOHOL WITHDRAWAL) 

PLAN OF CARE:
1.Inj. PAN 40MG /IV /OD
2.IVF 100ML NS 1AMPOULE OPTINEURON/IV
3.Inj. THIAMINE 100mg in 100ml NS/IV/TID.
4.Inj. ZOFER 4mg lV/TID
5. MONITOR BP,PR,RR
6.IVF - 0.9% NS
            DNS
 Continuous infusion@ 75ml/hr.

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