A 24 year old patient with history of vomiting

January 06, 2023

JANUARY 6th,2023

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A 24 year old male who is a resident of Nalgonda and band worker by occupation came with (31.12.22)

CHIEF COMPLAINTS:

.Vomiting since 10 days

.shortness of breath since 10 days

.Difficulty in swallowing and oral ulcers since 9 days.

.Decreased urinary output since 6 days.

.shortness of breath since 6 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 days back then he developed severe vomitings due to an excessive drinking of alcohol without any consumption of food. The vomitings were 4-5 episodes/day and were non bilious, non blood stained, non foul smelling, watery and occurred immediately after consumption of food or liquids. Also complaints of difficulty in swallowing since 9 days.

Patient developed oral ulcerations later that day. He was taken to a local hospital where medication (mouth wash and some gel for ulcers). was provided and did not get relief. 6 days ago he had complaints of shortness of breath (Grade 3) and decreased urine output with blood in the urine. Then went to a private hospital and endoscopy was advised and blood tests were done in which increased serum creatinine levels and bilirubin levels were detected and referred to our hospital and got admitted for dialysis. 5 days ago the patient was observed to develop a white coating in the mouth and over the tongue.

He has no H/o fever, loose stools, pedal oedema, pain abdomen, burning micturition, cold, cough .

PAST HISTORY:

No similar complaints in the past

No H/o HTN, diabetes, asthma, epilepsy and tuberculosis.

PERSONAL HISTORY:

Diet: mixed. Appetite: reduced

Bowel and bladder: irregular.

Sleep: adequate.

Addictions : alcohol consumption since 4 yrs daily( around 180 ml) (excessive drinking episode 2 days back before onset of present symptoms ) and paan occassionally.

Allergies: none.