A 44 year old male came to the OPD with complaints of chest pain, breathlessness, fever and left sided back pain

History of present illness

The patient was asymptomatic one month ago. He was taken to a local government hospital for chest pain and left sided back pain. He was brought to this hospital 10 days ago due to complaints of fever, loss of appetite with heavy alcohol consumption. 

He complained of pain and discomfort in the chest and upper abdomen which worsens on exertion (talking). He had shortness of breath and was unable to speak comfortably for more than a few minutes.

There is left sided pain in his back from the thigh to the lower back. He also had high grade fever with chills and rigors.

20 days ago, he behaved irrationally and was reported to have had hallucinations. 

There were a few episodes of vomiting with greenish discoloration while he was admitted in the government hospital. 

Past history

No history of diabetes, hypertension, TB, epilepsy or lymphadenopathy.

He was taken to a hospital due to the complaint of fever 4 years ago which resolved with medication in a few days.

7 years ago, he attempted suicide by consuming pesticide after being accused of theft. He was treated at a local hospital and recovered within a few days.

Personal history

Patient has been consuming alcohol since 15 years. He consumes about 300-360ml per day. He mentioned having a habit of consuming toddy before developing an addiction to alcohol. 2 years ago, he abstained from alcohol for two months. It has been 25 days since his last alcohol consumption.

He has a habit of chewing tobacco (since 15 years) and completes one pack in 2 days.

Normal micturition. He urinates about 5 times a day.

Loss of appetite since 10 days. 

Patient has had improper sleep for the past 20 days because of body pains.

Family history

No relevant family history.

Vitals

Respiratory rate: 25 per minute

Pulse: 130 bpm

Oxygen saturation: 98 %

(Measured at 11: 40 A.M. on 4th January, 2022)

General examination
 
Patient appears poorly built and poorly nourished.
Pallor present. Icterus present (yellowish discoloration of the sclera). No clubbing, No cyanosis. No lymphadenopathy or edema.
Yellowish discoloration of the palms was observed.















Systemic examination

CVS

Tachycardia present. Normal rhythm, volume, condition of arterial wall and no radio-radial delay.

Normal shape and size of the chest observed on inspection. 

No engorged superficial veins. No scars.

S1 and S2 were heard. No murmurs.

RS

Mouth-breathing present.

Normal shape and movements of the chest. Position of the trachea is central without any deviation to the sides.

CNS

Patient is conscious, coherent and oriented with space and time.

Investigations










Provisional diagnosis

Alcoholic liver disease, alcohol dependence syndrome. USG findings indicate emphysematous pyelonephritis.

Treatment

1% paracetamol i.v. (Anti-pyretic)

Normal saline

Tramadol (opiate analgesic)

Baclofen which is an anti-craving drug (skeletal muscle relaxant)

Lorazepam (benzodiazepine)

Pantoprazole (proton pump inhibitor. Used to treat heart burn)

Pregabalin (anti-convulsant)




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