alcohol withdrawal in known case of chronic alcoholic

1. Case presentation
Alcohol withdrawal in known case of chronic alcoholic
Presented by: Dr. Sheetal Savaliya
Guide: Dr. Ajita Pillai
Co-Guide: Dr. Shailesh Mundhava
3/18/2017
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2. History
 A 35 year old male patient from Wankaner- Morbi was admitted on
17/12/2016 with chief complaints of…
 Tremors and rigidity since 15 days.
 Past history : NAD
 Family history: NAD
 Personal history: Alcohol addiction since adolescence,
Alcohol withdrawal since 25 days.
3/18/2017
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3. Day 1(17/12/2016) Day 2(18/12/2016)
Temperature- Normal
Pulse - 78/minute
BP – 128/80 mm of Hg
RS – AEBE,
CVS – S1 S2 +
P/A – soft
CNS – conscious, disoriented
P/A – soft
Temperature- Normal
Pulse - 80/minute
BP – 124/80 mm of Hg
RS – AEBE,
CVS – S1 S2 +
P/A – soft
CNS – conscious, disoriented
U/O- 1.2 liter
Stool-not passed
Sp02-96%
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CLINICAL EXAMINATION:

4. Day 3(19/12/2016) Day 4(20/12/2016)
Temperature- Normal
Pulse - 80/minute
BP – 124/80 mm of Hg
RS – AEBE,
CVS – S1 S2 +
P/A – soft
CNS – Conscious, disoriented
U/O- 1.2 liter
Stool-not passed
Sp02-96%
Temperature- Normal
Pulse - 80/minute
BP – 124/80 mm of Hg
RS – AEBE,
CVS – S1 S2 +
P/A – soft
CNS – Conscious, oriented
U/O- 800 ml
Stool-passed
Sp02-96%
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5. Day 1 (17/12/2016) Day 2 (18/12/2016) Day 3 (19/12/2016)
Hb - 13.9 gm./dl Hb - 13.0 gm./dl Hb -13.5 gm./dl
WBC - 6400 cells/cumm WBC- 10400 cells/ cumm WBC - 7700 cells/ cumm
DC-79/18/02/01/00 DC - 85/13/01/01/00 DC - 82/16/01/01/00
PC - 2.8 Lacs / cumm PC - 2.31 Lacs / cumm PC - 2.1 Lacs / cumm
MP - not seen MP - not seen MP - not seen
RBS - 94 mg/dl RBS -182mg/dl
S.Creatinine - 1.0 mg/dl S.Creatinine - 1.0 mg/dl Prothrombin time: 16.4 sec.
S.Sodium - 132 mmol /L S.Urea - 24 mg/dl aPTT - 33
S.Potassium - 3.72 mmol / L Total Bilirubin - 1.1 mg/dl USG Abdomen - fatty
changes in liver ,rest NAD
S.HCV - Negative T.Protein -7.2 gm /dl P/S examination:
Normochromic, normocytic
HIV / HbsAg - Negative T.Albumin - 3-5 gm/dl
3/18/2017
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6. Treatment:
Day 1(17/12/2016) Day 2(18/12/2016)
Inj. Taxim 1 gm. iv 8 hourly Inj. Taxim 1 gm. iv 8 hourly
Inj. Metro. 1 piant iv 8 hourly Inj. Metro. 1 piant iv 8 hourly
Inj. Rantac/ Zoffer 1 amp. iv 12 hourly Inj. Rantac/ Zoffer 1 amp. iv 12 hourly
Inj. NS/RL 1 piant iv 12 hourly Inj. NS/RL 1 piant iv 12 hourly
Inj. D 25% iv 8 hourly Inj. D 25% iv 8 hourly
Liq. Duphalac 15 ml three times a day Liq. Duphalac 15 ml three times a day
Tab. Propranolol (40) half two times a day Tab. Librium(chlordiazopoxide) (10) three times
a day
Tab. Haloperidol(5) half two times a day Tab. Haloperidol(5) half two times a day
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7. Day 3(19/12/2016) Day 4(20/12/2016)
Inj. Taxim 1 gm. iv 8 hourly Inj. Taxim 1 gm. iv 8 hourly
Inj. Metro. 1 piant iv 8 hourly Inj. Metro. 1 piant iv 8 hourly
Inj. Rantac/ Zoffer 1 amp. iv 12 hourly Inj. Rantac/ Zoffer 1 amp. iv 12 hourly
Inj. NS/RL 1 piant iv 12 hourly Inj. NS/RL 1 piant iv 12 hourly
Inj. D 25% iv 8 hourly Inj. D 25% iv 8 hourly
Liq. Duphalac 15 ml three times a day Liq. Duphalac 15 ml three times a day
Tab. Librium(chlordiazopoxide) (10) tds Tab. Librium (10) three times a day
Inj. MVI 1 amp.in 100 ml NS once a day Inj. MVI 1 amp.in 100 ml NS once a day
Tab. lorazepam (2) sos Tab. lorazepam (2) sos 3/18/2017
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8. On the day of admission, bed side ophthalmologist reference
was done. Bilateral pupil and fundus examination was normal.
No papilledema was found. They advised to continue same line
of treatment.
Psychiatric reference was done on same day. They reviewed
case and noted history, history given by patient him self and
his wife as below.
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9.  Patients wife Complained of his irrelevant talk, fluctuating orientation,
not oriented to relatives, bed picking behavior, hand tremors and sleep
disturbance.
 Alcohol(country liquor) addiction since 25 years, daily intake
approximately 500-700 ml, last intake 25 days back.
 H/O delirium before 15 days,
 H/O withdrawal fit,
 No history of alcohol induced manic/psychotic/depressive disorder,
 No H/O blood in vomiting/stool,
 No H/O ascites/jaundice,
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10.  Family history: NAD
 Medical history: NAD
 Personal history: Alcohol and Tobacco use since 25 years.
 Patient was conscious ,oriented to place but not to time and person.
 Diagnosis: Alcohol delirium, alcohol use disorder.
 Advise given: Tab.Haloperidol(5) half tablet twise a day for behavior
disorder only.
 Follow up reference was done on 19/12/16, Advise given ,Tab. Haloperidol
(5) half tablet SOS for behavior disorder if any, Tab. Lorazepam (2mg) sos 1
Tablet for sleep disturbance.
3/18/2017
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11. Drugs:
 Cefotaxime: Antibiotic, third generation cephalosporin, it can not be
justified here.
 Metronidazole : Antimicrobial agent, not justified
 Propranolol: Beta adrenergic receptor antagonist, antagonise the effect of
excessive sympathetic effects like tremors.
 Librium (chlordiazopoxide): Long acting Benzodiazepine.
 Inj.MVI- Multivitamin injection. In chronic alcoholics vitamin deficiencies
are more common, but here in this case no any relevant clinical or laboratory
findings shows vitamin deficiency so it is not justified here
3/18/2017
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12.  Inj. D 25% - Dextrose 25% can be justified, to ensure adequate
availability of glucose in body.
 Tab. Haloperidol: Anti psychotic drug. For behavior disorder.
 Tab. Lorazepam: Intermediate acting benzodiazepine.
 Inj. Rantac– Ranitidine injection ,H2 receptor antagonist. Gastritis
can occur in case of chronic alcoholic.
 Inj.Zoffer- Ondansetron injection ,5 HT3 antagonist, as such there
is no role of it.
3/18/2017
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13. Comments:
 History was not taken properly, as they have not mentioned origin,
duration and progress.
 All the investigations required were done. Psychiatric and
ophthalmologist reference was done.
 In prescription, some drugs are prescribed by brand name and others
by generic name. It is advisable to prescribe drugs by generic name
and write in block letters.
 Abbreviations are used like SOS,NAD,TDS,BD.
 Rehabilitation is more effective, they should have to educate patient
and his family about that.
3/18/2017
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14. THANK YOU
3/18/2017
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