47 year old male with altered sensorium since 2 days and fever since 1 day with alcohol dependence, tobacco dependence and a K/C/O epilepsy

A 47 year old male, resident of Edavelli, labour by occupation presented to psychiatry OPD with 

Chief complaints - According to informant 
- C/O talking to self, physical and verbal abuse, increased anger outbusts and suspicion that people are trying to harm him and decreased sleep since 8 days on 10/12/23.

- C/o Drowsiness since 3 days
          Fever since 2 days

HOPI - 
Patient was undergoing treatment for Alcohol dependence syndrome, Tobacco dependence syndrome and Alcohol induced psychosis under psychiatry when he developed altered sensorium since 11/12/23 night and fever since morning of 12/12/23.

Background history - 



Past History - 

K/C/O seizures since 1 year ( 2-3 times per month under intoxication, not using medication) 
N/K/C/O DM, HTN, Asthma, TB.

Personal history - 

H/O alcohol consumption since past 35 years ( approximately 360/ml/day for past 20 yrs )

H/O tobacco consumption since past 35 years ( approximately 45 beedis/day)

Occasionally khaini since 20 years.

Diet: non-vegetarian 

Apetite: decreased

Bowel and bladder: regular

Sleep: disturbed 

GENERAL EXAMINATION:

Patient is drowsy with slurred speech and uncooperative, moderately built and malnourished.

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: present



VITALS:

Temperature: 97 F

Pulse: 126 beats/minute

Blood pressure:90/50mm Hg

Respiratory rate:26 cpm

GCS Score - E2V2M4

SYSTEMIC EXAMINATION - 

CVS - S1 S2 heard, no murmurs heard.

R/S - 

BAE present

Bilateral diffuse crepts present in Bilateral Infra axillary area and Bilateral Interscapular area.
Bilateral wheeze present.

Trachea- central

P/A -

Soft, non tender, no organo megaly

BOWEL SOUNDS HEARD

CNS - No focal deficit found.





Ecg on 12/12/2023

Ecg on 13/12/23





Provisional Diagnosis - 

Altered Sensorium under evaluation
? Aspiration pneumonia
Alcohol dependence syndrome
Tobacco dependence syndrome 
Alcohol induced psychosis 
K/C/O epilepsy 







Comments

Post a Comment

Popular posts from this blog

Internship in Medicine department

Image
I, Vaibhav Sai, worked as an intern in the department of General Medicine from 01/12/2023 to 31/01/24. 1) Self Reflective Writing on their medical student career -  My role as in intern involved looking after the patients in ICU, AMC, medical wards and the dialysis unit in various phases of my posting under the guidance of my PGs. Initially, I faced the challenges of having to deal with multiple patients in my unit, long shifts and the bureaucracy of work flow in our hospital. But, this initial discomfort helped me grow and face any further hurdles efficiently. I learnt the importance of taking a detailed history of the patient's complaints and the impact it had on their daily lives. I also improved my clinical examination skills during the posting. I was given the opportunity to perform and assist in various procedures. One of the key takeaways from this journey has been the realization that medicine extends beyond diagnosis and treatment but involves understanding the holistic ne...
Read more

60F WITH CAD CCF SINCE AUGUST 2023 WITH BLISTERING CELLULITIS SINCE SEPTEMBER 2023

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. Chief Complaints -  60 year old female presented with complaints of ulcer over the left since 1 month.  History of Present Illness -  Patient was apparently alright 1.5 month ago when she developed blisters...
Read more

35 year old male with sob

Image
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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This Elog book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment . CHIEF COMPLAINTS A 35 year old who is painter by occupation came with chief complaints of shortness of breath and fever since 1 week.  HISTORY OF PRESENT ILLNESS  Patient was apparently asymptomatic 1 week back, then he developed  • shortness of breath on exertion, since 1 week. • high-grade fever since 1 week, more during night, relieved on medication and relapses back. • decreased urine output since 1 week • dragging type of pain in both legs and hands, associated with gener...
Read more