30 year old male with SOB since 2 hrs

30 years old male  Working as farmer present to our casualty at 9:15 AM on 13/2/2022 with the 

chief complaint 

dyspnoea since 2 hours and and nausea since 2 hours

Cough since 2 days( started on 20/02/2022)


HOPI :

On 12th Feb 2022 at evening around 4 30  he consumed alcohol  following which the patient complained of generalised weakness and four  episodes of loose  stools . And two episodes of vomitings. Fever which was sudden in onset and was not reduced on medication 

At 4 AM on 13/02/2022  patient was hungry so he was given milk when  he was in supine position by his attender (mother) Following which the patient started to complain of nausea and he become tachypneic

Cough since 20/02/2022 which was non productive sudden in onset 

He an alcoholic since past 5 to 6 years with a intake of 90 to 180 ML of whiskey every day 

His daily routine was 

Wakes up gets ready and goes out irregularly goes to work eats very less at  home 



Past history : 

Not a known case of DM, HTN,TB,epilepsy, CAD, CVA.


Personal history :

Diet : mixed

Appetite : normal

Bowel and bladder moments : regular

Habits/addictions : he Is alcoholic since six years daily intake of whiskey 90 to 180 ML per day.

He chews tobacco one pack for day.



Family history : 

No significant family history


Genral examination : 

Patient is conscious, coherent , cooperative 

No signs of pallor , ictreus, clubbing , Sinuses lymphadenopathy , pedal edema.

Vitals : (on 21/02/2022)


Temp : afibrile 


Bp : 110/70 mm of hg


Pr : 60bpm


Rr : 32 cpm


Spo2 :95


Grbs: 99mg/dl




Systemic examination : 


Cardiovascular system : s1 , s2 heard , no murmur 


Respiratory system : 

all lung field are normal on percussion and auscultation 


Per abdomen : soft , non-tender , no organomegaly.


 Treatment : on admission 


1) head end elevation

2) inj.piptaz 2.25gm/iv/6th hrly

3) Nebuliaztions with mucomist 4th hrly and budecort 6th hrly

4) chest physiotherpay 12th hrly

5) inj.thiamine 1amp in 100ml Ns/iv/tid

6) monitor vitals hourly - bp,pr,spo2,rr

7) frequent suctioning of oral and nasal secretions 

treatment on 21 Feb 2022

provisional diagnosis 

Type 2 respiratory failure 

Aspiration pneumonia 

Alcohol dependence syndrome 



                 

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