44 yr old male pt.with SOB

Case History and Clinical Findings

44 yr old male pt came to the casualty withc/o loss of appetite since 1 monthcough with expectoration
since 10dayssob (grade4) since 4 dayspt was apparently asymptomatic 10 years back then he
developed loss of appetite ,yellow discoloration of sclera ,he went to local hospital and was told he
had jaundice releived on taking herbal medication for 10 daysthen he was fine till one month back
then he developed loss of appetite since then he had decreased intake of food then he developed
cough with expectoration sputum os scanty whitish in colour cough increases at night then he
devoloped Sob(grade 4) since 4daysno h/o fever ,cold, body Pains,headache,nausea,vomiting
,chestpain , Palpitations,orthopnea,pndPAST HISTORYN/K/C/O HTN,DM,ASTHMA,TB,
EPILEPSY,CADPERSONAL H/O:APPETITE DECREASEDDIET MIXEDSLEEP: ADEQUATEBOWEL
AND BLADDER: REGULARNO KNOWN ALLERGIESFAMILY HISTORY: NOT
SIGNIFICANTGENERAL EXAMINATION:PT IS C/C/CWELL ORIENTED TO TIME ,PLACE AND
PERSONNO PALOR, ICTERUS ,CYANOSIS, LYMPHADENOPATHY, EDEMAVITALS AT
ADMISSION:BP: 100/60MMHGPR: 120BPMRR: 18CPMSPO2: 90%AT RASYSTEMIC
EXAMINATION:CVS - S1 S2 + NOMURMURS,JVP NOT RAISEDRS - BAE + , CREPTS + IN LEFT
IAA AND LT.ISAREMAINING AREAS NVBS HEARDOTHER AREAS- NVBS HEARDP/A - SOFT
NON TENDER, ON PERCUSSION TYMPANIC NOTE HEARD ,BS +CNS -RHOMBERG
POSITIVEGAIT NORMALMOTOR UL LLPOWER. RT 5/5. 5/5 LT 5/5. 5/5TONE. RT N N LT N
NCOURSE IN THE HOSPITAL :a 44 yr oldmale with background history of alcohol abuse since 25
yrs and smokingsince 20 years came to casuality with above mentioned complaintschest xray
revealed rt middle lobe consolidation .hemogram showed bicytopenia ( anemia and
thrmobocytopenia) folic acid defeciency .on the day of admission at night 1;30am he had
alcoholicwithdrawal seizuresresolved patient was started treatment with iv inj augmentin 1.2 g ,inj pan
40 inj thiamine inj optineuron tab hepamerz tab udiliv tab dolo syp aptivate syp potchlor for pottasium
correctionafter psychiatry refferal on advi
se of psychiatrist he was started treatment on tab loraz 2mg , tab baclofen,tab benfotamine inj vit kvit
b12 levels >2000 folic acid 2.3pottasium corrected
Investigation
USG ABDOMEN : IMPRESSION- GRADE 1 FATTY LIVER
CHEST XRAY : RIGHT MIDDLE LOBE CONSOLIDATION
2D ECHO:
NO RWMA ,MILD LVH +
MILD AR+ ,TRIVIAL TR+,NO MR
SCLEROTIC AV ,NO AS/MS
EF 60% RVSP 35MM HG
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION +,NO PE/PAH
IVC SIZE 1.15CM
SPUTUM C/S : NORMAL OROPHARYNGEAL FLORA GROWN
HEMOGRAM :
HB- 6.8
TC 5400
PCV 20.8
MCV 128.4
MCH 42
MCHC 32.7
RDW 16.7
RBC 1.62 MILLION /CUMM
PLT 1.1LAKH/CUMM
Diagnosis
1)? ALCOHOLIC LIVER DISEASE2)RIGHT MIDDLE LOBE CONSOLIDATION..? CAP.? TB (
RESOLVED)3) BICYTOPENIA SECONDARY TO FOLIC ACID DEFECIENCY4)WITH? ALCOHOL
WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)(RESOLVED)
Treatment Given(Enter only Generic Name)
O2 INHALATION if O2 sat <90%INJ AUGMENTIN 1.2g IV BDINJ PAN 40 MG PO ODINJ THIAMINE
200mg IN 100ML NS IV BDOVER 30MININJ VIT B12 1500MICROGM IN 100ML NS IV ODTAB
FOLIC ACID 1MG PO ODTAB UDILIV 300mg PO BDTAB PCM650 MG PO SOSSYP GRILLINCTUS
15ML PO TIDSYP APTIVATE 15ml PO BDSYP POTCHLOR 10ml in 1 GLASS OF WATER PO
TIDINJ VIT K 1AMP +100ML NS OVER 10MINTAB HEPAMERZ 500 mg PO ODBP MONITORING
2nd HRLY AND VITALS 4rth HRLYFOLLOW PSYCHIATRIC ORDERST LORAZEPAM 2 MG (1-1-
2)TAB BACLOFEN XL 20MG PO OD HSTAB BENFOTAMINE 100MG PO ODADEQUATE
HYDRATION
Advice at Discharge
2 EGG WHITESTAB AUGMENTIN 625 MG PO THRICE DAILY X 2DAYSTAB VIT B12
1500MICROGM ORALLY THRICE DAILYSYP GRYLLINCTUS 15MLPO SOST OROFER XT PO
TWICE DAILY X15 DAYSTAB PANTOP PO ONCE DAILY BBF X 3DAYSTAB BENFOMET 100 MG
ORALLY ONCE DAILY FOR 15 DAYST LORAZEPAM 2 MG (1-X-2 today) x-x-2 for 3 days x-x-1 for 5
daysTAB BACLOFEN XL 20MG PO OD (x-x-1)NICOTINE GUMS 2MG SOSSTRICT ALCOHOL
ABSTINENCE
Follow Up
REVIEW TO THE GEN MED OPD AFTER 2 WEEKS OR IN CASE OF SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.


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