Chest pain from 1 week back
Stomach pain and generalised weakness since 2 months.
History of present illness-
The patient was apparently asymptomatic 1 year back, then he was married and since he was a chronic alcoholic since 15 years age, he used come home drunk after a very tiring day of work and that used to anger his wife and she would leave him for days and because of that he ate at hotels and this went on for many months and which made him take loans which he couldn't pay or compensate and he got beaten up a lot and he has multiple wounds all over his body and face.
One day his wife got pregnant. She was stressed until she couldn't take it anymore and when she was 3 months pregnant she left the house and dint come back yet (now his son is now 3 months old). The in laws wouldn't treat him right and that would frustrate him making him drink more and he used to often fall on the roads unconscious and used be taken home by neighbours who would find him on the streets.
2 months back he fell from a 10 feet wall and from then he complains of severe pain in the neck.
From 1 month back he c/o generalised body pains dragging type.
Recently 1 week 10 days back he was involved in a RTA and sustained minor injuries over his face and head and tenderness in right side abdomen and back.
For all his complains he went to a private hospital where he spent 70000 (stressed by the patient) and all the tests were done and it showed e/o infection of the gall baldder.
He complains of Chest pain since 1 week and also increased frequency of vomitings from 1 week and productive cough since 2days.
Past history :
No h/o DM, HTN, TB, BA, Epilepsy and thyroid abnormalities.
Family h/o:
No similar complaints in family
No h/o DM, HTN, TB, BA, Epilepsy, CVA, CAD.
Personal h/o:
Diet- mixed
Appetite-reduced
Sleep- not adequate
Bowel and Bladder movements- Regular
Addictions: consumption of alcohol (beer)since age 15.
O/e: General Examination:
Patient is C/C/C
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
Vitals:
Temp - afebrile.
PR- 90 bpm
BP- 150/90 mmHg
RR- 14 cpm
SpO2- 98% at RA
Investigations:
Treatment:
1. INJ. PAN 40 MG IV OD
2. INJ. ZOFER 4 MG IV BD
3. INJ. OPTINEURON 1 AMP IN 100 ml NS IV OD
4. INJ. LORAZEPAM 1 AMP/ 4 MG IM
5. IVF NS and RL at 75 ml/hr
6. INJ. THIAMINE 1 AMP in 100 nl NS IV TID
7. TAB. LIBRIUM 25MG for 2 days
1.....1.....1.....2
8. TAB BACLOFEN XL 20 MG for 2 days
1.....X.....1
9. Tab PCM 650MG PO SOS