GENERAL MEDICINE CASE DISCUSSION

 

60YEAR MALE WITH ALCOHOL WITHDRAWAL AND ERYTHRODERMA SINCE 4 MONTHS 

 May 20 , 2023

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CASE:-

 A 60yr old male who is a vegetable wender by occupation resident of chityal came  to OPD with cheif complaints of erythematous patches all over the body since 4 months.

History of presenting illness: 

• Pt . Was apparently asymptomatic 8 yrs back then he experienced giddiness while selling Vegetables and went to RMP and was diagnosed with HTN and was started on T. Olmesartan -H OD since then which pt has been taking regularly till last 20 days

• 5yrs ago - pt experienced chest pain , he assumed it to be due to acidity yet went to a RMP and got tested and was refered to cardiologist in view of abnormal ECG and was diagnosed with CAD and started on T. ECOSPRIN -AV 75/10 H/S since then which pt has been takin regularly till last 20 days

• October 2022 - pt experienced extreme joint pains( especially knee pains ) and went to RMP , was told had weak bones and was given medication for 15 days , after use of which the pains reduced 

• October 2022- pt also experienced bilateral pedal edema which he assumed to be because of long sitting hours while selling Vegetables , when the edema didn't reduce he went to RMP and on testing was found out there was elevated uric acid and medication ( no documentation found) was given for 1 week and after the use of prescribed medication pedal edema has subsided.

• January 2023( 4 months back) - pt noticed two skin  lesions over the right lower limb near the ankle and went to RMP and he was told it could be due to allergic reaction to insect bite . One week after the lesions he had alcohol and there was exaggeration of the pre existing lesion and he developed new lesions all over the body . Lesions were red , itchy and associated with burning sensation, photo sensitivity present , no fever and consulted a doctor in nalgonda and was started on treatment . After using the treatment the lesions reduced but not completely resolved .

• 20 days back - stopped medicines for HTN and CAD as he felt he has been taking too many medicines 

• 15 days back - pt experienced bilateral pedal edema extending upto knees pitting type , giddiness and decreased urine output .

• 1 week back - c/o fever , subsided on taking TAB. DOLO 

                Decreased sleep - as he is experiencing pricking type of pain in the skin lesions 

                 Decreased appetite

• No h/o SOB, chestpain , palpitations , PND , orthopnea 
• No h/o facial puffiness, burning micturation , pain abdomen
• No h/o polyuria , polyphagia , polydypsia.

Personal history 

Marital status : married 

Diet : mixed 

Appetite : decreased since 1 week

Bowel and bladder: decreased urine output since 1 week , bowel - regular

Sleep : reduced since 1 week

Addictions : 

A chronic alcohol for 40 years and increased consumption since 3 months. ( 12-14 units)

And tobacco consumption in form of chewables for 43 yrs and increased consumption since 10 years ( 1pqck/2 days)

General physical examination 

Patient was concious coherent cooperative well built and nourished , well oriented to time place and person  at the time of presentation.

Pallor : absent 

Icterus : absent

Cyanosis : absent 

Clubbing  : present

Lymphadenopathy : absent 

Edema : absent

Skin:   Generalized erthyema with scales noted all over the body sparing face

Nails : normal

Scalp: hypopigmented macules present

Vitals 

Temperature : 98.6° F   (afebrile)

PR : 76 bpm

BP : 120 / 80 ( 18/5/23 , 12pm) 

RR : 14 cpm

Spo2: 98 on RA

Systemic examination

CNS  examination: 

HIGHER MENTAL FUNCTIONS:

Oriented to time place and person 

Immediate memory:Intact

Short term memory:Intact

Longterm memory:Intact

No delusions and hallucinations.

Motor system

Power:-

Rt UL - 5/5 Lt UL-5/5

Rt LL - 5/5  Lt LL-5/5

Tone:-

Rt UL - normal

Lt LL- normal

Rt LL- normal

Lt LL- normal

Reflexes: 

                   Right                    Left

Biceps:      ++                    ++

Triceps:       ++                  ++

Supinator:  ++                   ++

Knee:         ++                    ++

Ankle:            + +                 ++

Plantar:      flexor.         Flexor

Involuntary movements - absent

Fasciculations - absent

Sensory system - 

-Pain, temperature, crude touch, pressure sensations,Fine touch, vibration, proprioception -normal

Autonomic nervous system - normal

• Meningeal sign - negative 

P/abdomen : 

On inspection : obese abdomen

Erthyematic patches and scaling present over abdomen

No visible scars and sinuses , engorged veins

Umbilicus : central and normal 

On palpation : soft and non tender 

On percussion : no free fluid present 

On auscultation : bowel sounds were heard

CVS EXAMINATION 

S1S2 heard,no murmurs.

Respiratory system examination

Bilateral air entry present.

19/ 05/2023

Pt was in male medical ward and around 9:30am BP: 70/40 mmHg noted and was shifted to medicine ICU i/v/o hypotension

Measure to correct hypotension at that point: 

Iv cannula secured and 100ml NS bolus was given and pt was started on  maintainance fluid of 100ml/hr NS 

 post fluids vitals  at 10:30am  

BP: 100/60mmhg 

PR : 102bpm 

Pt. Was started on NORAD aPt. Was started on NORAD at 20/5/23 2am as the pt. Wasn't maintaining blood pressure .

 INJ. NORAD 2AMP IN 4-6ML NS @ 4ML/HR

Psychiatry referal was put i/v/o ALCOHOL WITHDRAWAL and tobacco consumption on 19/5/2023

Pt was apparently asymptomatic 40 years back then started consuming alcohol in form of toddy , initially he used to consume 2 units , occasionally on family gathering and for bodypains. 

This pattern of drinking habit continued for 32 years , since 8 years , pt. Reports , due to financial stressors he started consuming alcohol in form of whiskey, initially he used to consume 90-180 ml ( 3-6 units ) , every day at night mostly .

Pt reports itchy skin lesions all over the body since 4 months to releive this symptoms he used to consume more nearly 12-14 units / day since 4 months and also for better sleep

Pt reports urge to take ALCOHOL present .

Pt experiening tremors , sleep disturbances if he doesn't consume alcohol

Pt continued to drink alcohol despite knowing it's harmful effects.

Pt also reports history of tobacco consumption since 43 years in form of chewable , intitally he used to consume 2-3times / days ( 1 packet per 5 days ) it gradually increased to 1 packet per 2 days 

 Pt experiening constipation and irritation if he doesn't consume tobacco.

Craving for tobacco present 

Pt continued to take tobacco despite knowing harmful effects

Last drink on 18/5/2023 - 6 units

Last tobacco on 18/5/2023 morning

Self care and hygiene maintained.

Able to do daily activities

H/o occasional low mood , suicidal ideation ( since 1 week)

MSE : 

 pt. Lying on the bed comfortably responding well to oral commands , well built , iv cannula in place 

Rapport established

ETEC + sustained

PMA increase

Tremors ( mild to moderate)

Speech normal and relevent and coherent

Mood : parledu

Affect : euthymic 

Oriented to time , place , person 

IMP: 

1. ADJUSTMENT DISORDER WITH DEPRESSION

2. ALCOHOL DEPENDENCE SYNDROME currently in withdrawal

3. TOBACCO DEPENDENCE SYNDROME

TREATMENT: 

1. TAB.PREGABALIN 75MG PO/ OD

2. TAB.LORAZEPAM 1MGVPO/OD ( MRNG)

3. TAB. LORAZEPAM 2MG PO/ OD ( NIGHT)

4. NICOGUMS 2MG /PO TID

5. THIAMINE SUPPLEMENTATION 

20/5/2023

S: pt is irritatable and restless and subjectively not oriented to time and place 

O: 

On examination:

Pt is irritatable, restless 

Temp: 101degreeF

PR: 120bpm

BP: 80/50mmhg

Rs: BAE + , NVBS + 

CVS : s1 s2 heard

P/A: soft, non tender

CNS: can't be elicited

A:

ERTHYRODERMA UNDER EVALUATION

ALCOHOL DEPENDENCE SYNDROME IN WITHDRAWAL

TOBACCO DEPENDENCE SYNDROME

P: 

IV FLUIDS NS @100ML/HR

INJ. NORAD 2AMP IN 4-6ML NS @ 6ML/HR TAPER ACCORDING TO MAP , MAINTAIN MAP> 65

INJ. THIAMINE 200MG IN 100ML NS /IV/ TID

TAB. PREGABALIN PO/HS

TAB. DOLO 650MG PO/TID

Psychiatry followup:( 8 AM)

Pt reports to have not slept last night

Pt is irritatable and trying to get up since Midnight( 12am) , increased since 7am

Icu staff reported that he removed his iv cannula 2 times since last night 

Pt is oriented to person not to time and place 

P: 

inj. LORAZEPAM 2mg / IM/ STAT

Nicotine gums 4mg po/sos

Tab . Chlordiazepoxide 25mg po/bd

21/05/2023:

 S : pt not talking much , pt is irritatable and restless and subjectively not oriented to time and place 

O: 

On examination:

Pt is irritatable, restless

PR: 116bpm

BP: 80/60mmhg

Rs: BAE + , NVBS + 

CVS : s1 s2 heard

P/A: soft, non tender

CNS: can't be elicited

Grbs : 113mg/dl

A:

ERTHYRODERMA UNDER EVALUATION

ALCOHOL DEPENDENCE SYNDROME IN WITHDRAWAL

TOBACCO DEPENDENCE SYNDROME

P: 

IV FLUIDS NS @100ML/HR

INJ. NORAD 2AMP IN 4-6ML NS @ 6ML/HR TAPER ACCORDING TO MAP , MAINTAIN MAP> 65

INJ. THIAMINE 200MG IN 100ML NS /IV/ TID

TAB. PREGABALIN PO/HS

TAB. DOLO 650MG PO/TID

VENUSA max lotion L/A BD

Tab. Dolo 650mg po/ tid

Psychiatry followup:( 8 AM)

Pt is lying on bed , waking up in strong stimulus opening eyes , responding to commands upon repeating.

Pt didn't slept whole night, irritable and shouting on attenders and occasionally on  staff.

Tring to get up from bed and walk away

Irrelevant talk in form of not recognising room but able to recognise attenders 

Pt occasionally asked for alcohol with son

Pt is oriented to person not to time and place 

TREMORS MODERATE 

P: 

INJ. HALOPERIDOL 5MG IM SOS

Nicotine gums 4mg po/sos

Tab . LIBRIUM 25MG PO/BD

22/05/2023:

S: pt is not talking and is drowsy, irritable and restless

O:

On examination:

Pt is drowsy

Temp: 100.5 

PR: 116bpm

BP: 110/70mmhg

Rs: BAE + , NVBS + 

CVS : s1 s2 heard

P/A: soft, non tender

Grbs at 8am : 121mg/dl

A:

ERTHYRODERMA UNDER EVALUATION

ALCOHOL DEPENDENCE SYNDROME IN WITHDRAWAL

TOBACCO DEPENDENCE SYNDROME

P: 

IV FLUIDS NS @100ML/HR

INJ. NEOMOL 1GN / IVV/ SOS (if temp>101)

INJ. THIAMINE 200MG IN 100ML NS /IV/ TID

TAB. PREGABALIN PO/HS

TAB. DOLO 650MG PO/TID

VENUSA MAX LOTION L/A BD

 Pyschiatry followup:( 8 AM)

Pt have slept well last night

Irrelevant talk and mumbling in sleep occasionally 

Pt occasionally asked for tobacco to wife

Pt is drowsy , responding to commands , no hallucinatory behaviour observed

No tremors 

No craving for alcohol and tobacco

Oriented to time , place , person 

P: 

INJ.DIAZEPAM 1AMP ( 10MG ) / SLOW IV IN 100ML NS OVER 20 mins /sos

T. Chlordiazepoxide 25mg / BD

23/05/23

S: pt is not talking and is drowsy

O:

On examination:

Pt is drowsy but arousable

Temp: 99.5F 

PR: 115bpm

BP: 110/70mmhg

Rs: BAE + , NVBS + 

CVS : s1 s2 heard

P/A: soft, non tender

2 fever spikes since yesterday night 

A:

ERTHYRODERMA UNDER EVALUATION

ALCOHOL DEPENDENCE SYNDROME IN WITHDRAWAL

TOBACCO DEPENDENCE SYNDROME

P: 

IV FLUIDS NS @100ML/HR

INJ. NEOMOL 1GN / IVV/ SOS (if temp>101)

INJ. THIAMINE 200MG IN 100ML NS /IV/ TID

TAB. PREGABALIN PO/HS

TAB. DOLO 650MG PO/TID

VENUSA MAX LOTION L/A BD

24/5/23

S : Pt is not talking and his drowsy

O:

On examination:

Pt is drowsy but arousable

Temp: 99.5F 

PR: 105bpm

BP: 110/70mmhg

Rs: BAE + , NVBS + 

CVS : s1 s2 heard

P/A: soft, non tender

2 fever spikes since yesterday night 

A:

ERTHYRODERMA UNDER EVALUATION

ALCOHOL DEPENDENCE SYNDROME IN WITHDRAWAL

TOBACCO DEPENDENCE SYNDROME

P: 

IV FLUIDS NS @100ML/HR

INJ. NEOMOL 1GN / IVV/ SOS (if temp>101)

INJ. THIAMINE 200MG IN 100ML NS /IV/ TID

TAB. PREGABALIN PO/HS

TAB. DOLO 650MG PO/TID

VENUSA MAX LOTION L/A BD

Tab. ACITRETIN 25MGBOD

NMFE LIP BALM TID L/A

Psychiatry followup:( 8 AM)

Pt have slept well last night 11:30PM to 5:00AM and slept again till 7am

Pt.complaints of itching sensation at night 

Pt occasionally asked for tobacco to wife

No abnormal behaviour and irrelevant talk

C/o weakness in Rt. LL and UL

Pt is drowsy , responding to commands , no hallucinatory behaviour observed

No tremors 

No craving for alcohol and tobacco

Oriented to  place , person 

Confused about time

P: 

T.LIBRIUM 25MG /PO/ BD

INJ. LORAZEPAM 4MG IM SLOW IV IN 100ML NS

24/05/23

S: pt is not talking and is drowsy

O:

On examination:

Pt is drowsy but arousable

Temp: 99.5F 

PR: 115bpm

BP: 110/70mmhg

Rs: BAE + , NVBS + 

CVS : s1 s2 heard

P/A: soft, non tender

2 fever spikes since yesterday night 

A:

ERTHYRODERMA UNDER EVALUATION

ALCOHOL DEPENDENCE SYNDROME IN WITHDRAWAL

TOBACCO DEPENDENCE SYNDROME

P: 

Psychiatry followup:( 8 AM)

Pt have'nt slept well last night ( because of discomfort in abdomen) and sleeping since 6 am

Pt.complaints of itching sensation at night 

Denies any craving for alcohol and tobacco 

No abnormal behaviour and irrelevant talk

C/o weakness in Rt. LL and UL

Pt is drowsy , responding to commands , no hallucinatory behaviour observed

No tremors 

No craving for alcohol and tobacco

Oriented to place , person 

Confused about time

P: 

T.LIBRIUM 25MG /PO/ BD

INJ. LORAZEPAM 4MG IM SLOW IV IN 100ML NS