60M COMA WITH POSSIBLE ALCOHOLIC DELIRIUM TREMENS ON MECHANICAL VENTILATION 4 DAYS

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60yr Old male who is an farmer & shepherd . Married at age of 18yrs (3sons).
Daily routines
 Wakes up @ 4am
4am-8am goes to cattle farm and draw milk from buffaloes.
8am drinks some tea and goes to farm and returns back to home around 10am
10am eats rice and takes cattle to field .
2pm eats rice in the filed ,which he carries from home.
2pm to 5pm does some farm work and look after the cattle.
6pm returns back to home along with his cattle.
6pm to 8pm talks with his friends, drinks alcohol and have some smoke.
8pm eats rice and goes to sleep at 9pm.
ADDICTIONS:
Started smoking at the age of 18yrs(10-15 beedis /day). 
Drinks alcohol occasionally from the age of 18 years 
but from past 20 years he is taking alcohol regularly 90ml/day (after his childern got married and settled he started taking alcohol regularly )

HOPI: 
Pt was apparently asymptomatic 1yr back then gradually developed pain and swelling in left inguinal region ( *reducible* hernia) ,and used to have pain abdomen on & off since then.But not visited to any doctor. 
Pt had h/o cough (on &off ) with sputum since 1yr but not visited to any doctor.
Now Since 7 days pt is having vomiting (10 episodes, bilious)and dragging time of left sided loin pain with swelling.
Pt went to outside hospital on 14/5/23.
On 14/5/23 @ admission
Pt c/c/c Bp 130/80 
                PR 84bpm
                *Spo2 88% @ RA* and 
                 96% @ 4lit 02.
Pt had *IRREDUCIBLE* HERNIA and got operated( inguinal exploration+ mesholasty under spinal anes) on SUNDAY (14/5/23).
On MONDAY(15/5) evening around 5pm pt recovered from anesthesia effect and was conscious.
On TUESDAY (16/5)---POD-2 since afternoon pt started to talk irrelevantly, then he had craving for alcohol and smoking and started to use abusive words against treating nurses, doctors and family members (Alcohol withdrawal) for which they restrained him for whole night.
On WEDNESDAY ( 17/5/23)pt was irritable, craving for alcohol and smoking increased and they gave syrup+water in glass similar colour to whiskey (Placebo) craving for alcohol decreased and he started asking for smoke but they didn't give him smoke.on Wednesday night 10pm pt Lama from hospital and went to home.
On THURSDAY ( 18/5) pt still irritable and was restrained by his wife. He had idly and ragi jawa around 10am . His friends and relatives started to visit his house , pt was able to recognise them but not speaking to them fluently like before.Around 5pm-6pm pt started to have excess breathing with sounds (tachypnea + ? Stridor/? grunting) pt was tachypnic whole night.
On FRIDAY (19/5/23) @ 8am pt was taken to same hospital were he got operated,on admission pt GCS was E2V2M3. Pt managed with iv fluids, antiboditics .
20/5/23 iv fluids antiboditics continued.
21/5/23 his saturation and B.P started to fall ,i/v/o falling saturation and low GCS pt was intubated and connected to ventilator and ionotropes were started.
22/5/23 pt was on ventilator, ionotropes continued .
23/5/23 pt shifted from outside hospital to our hospital on ventilator.

General examination 
No pallor icterus clubbing lymphadenopathy edema 


Systemic examination
CVS: S1, S2 heard. No murmurs.
RS: BAE+, NVBS heard.
P/A : soft, NT, no organomegaly. CNS:
GCS - E1VntM1
Pupils - reactive
Tone : R L 
UL hypo hypo
LL hypo hypo
Power:
UL 0/5 0/5
LL 0/5 0/5

Reflexes R L
Biceps - -
Triceps - -
Supinator - -
Knee - -
Ankle - -
Plantar - -

Provisional diagnosis
HOSPITAL AQUIRED PNEUMONIA (ACINETOBACTER) VEGETATIVE STATE SECONDARY TO DEMYELINATION IN PONTINE AND EXTRAPONTINE WITH ?HYPOXIC ISCHEMIC ENCEPHALOPATHY WITH S/P TRACHEOSTOMY (POD-6) - TUBE CHANGED IN 3/6/23
WITH S/P HERNIOPLASTY ON 15/5/23
WITH RECURRENT HYPOKALEMIA 
WITH GRADE IV BED SORE 

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