26 year old male patient with SOB

 This is an online E-log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section. 




 26 year old male patient barber by occupation came to the casuality with chief complaints of : 

•  shortness of breath since afternoon 

HOPI : 

Patient was apparently asymptomatic 2 months ago 

patient has a history of alcohol consumption since 2 years, 1-2 glasses of beer occassionally 

patient complaints of shortness of breath, grade 2, on and off since 2 months. 

Current episode of grade 4 Sob started since afternoon.

• Last binge of alcohol yesterday morning 

• No intake of eating food since 3-4 days since he was drinking alcohol. 

2 episodes of vomiting, yesterday evening and today morning. 

No complaints of syncopal attacks. 

PAST HISTORY : 

N/K/C/O. HTN,DM, EPILEPSY, ASTHMA, TB , CAD  

PERSONAL HISTORY : 
Appetite: Normal
Diet: mixed diet 
Sleep: Adequate 
Bowel and bladder movements normal 
Addictions: Alcohol consumption since 2 years, whiskey daily, occasionally binge drinking. 

FAMILY HISTORY : 
No relevant family history. 

GENERAL EXAMINATION : 

Patient was conscious , coperative , coherent 

pallor , icterus, cyanosis, clubbing, lymphadenopathy,edema are ABSENT 

vitals : 

Temp: afebrile 
BP: 120/80 mm hg 
PR: 120 bpm.
RR : 28 cpm
SpO2:  98 @RA 
GRBS : 42 mg% 


SYSTEMIC EXAMINATION  : 

CVS :- S1 , S2 heard 

RS. :- bae present 

P/A : soft , non tender 

CNS :- The patient is conscious coherent and oriented to time place and person 
No Focal Neurological Deficits

INVESTIGATIONS : 

Ultrasound

ECG 

Hemogram

Ketone Bodies 

Blood Urea 

Liver Function Test 

Sr. Electrolytes 

ABG 

RBS 

HCV Antibodies: Negative ( RAPID, ELISA) 

TREATMENT HISTORY : 

Day 1 

1. Normal diet + plenty of oral fluids 
2. 2 NS @75ml/hr  , 1 DNS @ 50ml/hr
3. Inj. PAN 40mg / IV / OD 
4. Inj. ZOFER 4mg/ IV / SOS
5. Inj. THIAMINE 100mg 1 ampule in 100 ml NS / IV / TID 

Day 2 

1.Inj. PAN 40mg / IV / OD 
2.  Inj. ZOFER 4mg/ IV / TID
3.  Inj. THIAMINE 100mg 1 ampule in 100 ml NS / IV / TID 

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