🚀 go-pugleaf

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