🚀 go-pugleaf

Good point Mr. Lee, that was deliberate to see when some one would ask
for it- but in this case the mental status exam would have been of
more use. Please see the case resolution posted today.

thanks and keep watching!

ck

Paul Lee <leexx189@tc.umn.edu> wrote:

>Ah, Dr Krin, you left out the neuro exam.  Does he have sign of
>neuropathy?  Does he have delayed deep tendon reflex release?  What is
>his auditory acuity?  Does he have any hallucination?  Any tremor?
>
>The salient feature is profound dyspnea with bilateral crackles and
>pedal edema, cold intolerance, auditory/visual acuity loss, clubbing,
>irritability, mild jaundice.  Based on info supplied so far, some of the
>considerations are:
>
>(1)Non-ETOH stuff (ETOH is a red herring)
>A. Hypothroidism/Myxedema (cold intolerance, hearing acuity change,
>edema)
>B. Grave's. (CHF, clubbing, irritability, tachycardia)
>C.  Others: pneumonia, P.E. >>> I really doubt. That would be too
>boring.
>D.  HIV (e.g. PCP)/ TB type of stuffs.  Lower on my DDx but must be kept
>in mind.
>
>(2)ETOH
>A. Beriberi and thiamine deficiency (edema+ crackle + SOB suggests CHF. 
>In this scenario thiamine deficiency is commonly seen in case
>presentation if not in real life.)
>Does he have neuropathy?  
>B. ETOH cardiomyopathy
>C. Liver failure>>>renal failure>>>fluid overload
>D. Methanol/ethylene glycol ingestion with renal failure.  What is in in
>that "Thunderbird" bottle?  Is it just a cheap wine or is there
>something else?  What do you smell?
> 
>Additional historical items: where and how did he get his booze? The
>duration of his dyspnea and pedal edema as well as probable ascites? 
>Took anything else, like cocaine?
>
>In addition to the usual stuffs (SMA20/CBC/Osm, u/a, ABG, stat CXR, EKG,
>iv, oxygen, rhythm and sat monitor), we need to get tox screen, alcohol
>levels (ethanol,methanol, and ethylene glycol), thyroid tests.  He needs
>thiamine as well as other vitamins.  Cardiac echo to document heart
>function would be nice, but then he has no insurance so it may be tough
>to get and this could wait.  
>
>
>Paul Lee

Charles S. Krin, DO FAAFP KC5EVN, Member, PGBFH
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"Reckless, Hell! I hit jus' where I was aimin'"
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