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 







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