2. SUBJECTIVE
Name of patient: XYZ
Age: 55yrs
Sex: Male
DOA:19/4/15
Complaints: Altered sensorium, loss of consciousness
since morning.
History of disease: Shrunken eye on left side since 3
months
CNS: Left eye enopthalus.
GI: Not coherent
Personal Habits: Chronic alcoholic +
3. OBJECTIVE
BP:130/90mmhg
PR:84/min
RR:18/min
Temp:afebrile
Random Blood Sugar: 134 mg/dl.
Serum Urea: 22 mg/dl
Serum Creatinine: 0.9 mg/dl
Sodium:139 mEq/ L
Potassium: 4.6 mEq/
CT Scan of Brain: Diffuse cerebral atrophy; pthysis bulby of left
eye.
6. Drug brand
name
Generic
name
Indication Dose Route of
administratio
n
Fr
eq
ue
nc
y
I.levoflox levofloxacin antibiotic 750mg IV OD
I.pantop pantaprazole Proton pump
inhibitor
40mg IV OD
I.metrogyl metriondazol
e
antibiotic 100ml IV TI
D
25%dextrose
IVF
dextrose Glucose
supplement
I.mannitol mannitol Osmotic
diuretic
100ml IV TI
D
I.piptaz pipperacillin antibiotic 4.5mg IV TI
D
I.neurogard multivitamin vitaminsupple
ment
IM OD
7. Patient counselling regarding disease state
Alcohol withdrawal syndrome: is a set of symptoms that can
occur when an individual reduces or stops alcoholic consumption
after long periods of use. Prolonged and excessive use of alcohol
leads to tolerance and physical dependence. The withdrawal
syndrome is largely a hyper-excitable response of the central
nervous system to lack of alcohol.
Symptoms typical of withdrawal include agitation, seizures, and
delirium tremens.
8. Patient counselling regarding medication
Optineuron:
Opti neuron Tablets (Vitamin B12 (Cyanocobalamin)) refers to a
group of water-soluble vitamins. It has high biological activity.
Adverse effects:.Drowsiness 2.Headache 3.Diarrhoea 4.Nausea.
5.Numbness of the skin
Librium: is used to treat anxiety and acute alcohol withdrawal. It
is also used to relieve fear and anxiety before surgery. This
medication belongs to a class of drugs called benzodiazepines
which act on the brain and nerves (central nervous system to
produce calming effect.
9. Adverse effects:
Fainting
mood or mental changes
shakiness and unsteady walk
unsteadiness, trembling, or other problems with muscle control or
coordination
Levofloxacin: is a broad-spectrum antibiotic of the
fluoroquinolone drug class, and the levo isomer of its predecessor
ofloxacin. Its spectrum of activity includes most strains of
bacterial pathogens.
11. Metriondazole: a generic synthetic antibacterial compound
available for both oral and intravenous use. It is indicated in the
treatment of serious infections caused by susceptible anaerobic
bacteria.
Adverse effects:
dizziness, loss of balance;
vaginal itching or discharge;
dry mouth or unpleasant metallic taste;
cough, sneezing, runny or stuffy nose; or.
swollen or sore tongue.
12. Patient counselling regarding life style
modification
Avoid seizure triggers as alcohol, lack of sleep, stress,
recreational drugs.
Avoid anxiety and sadness.
Avoid smoking, tobacco.
Exercise regularly.
Avoid triggers as flash lights, computer screens, etc; though they
have little effect in recurring.
Eat healthy diet rich in vitamins and minerals.
Limit alcohol intake.
14. DRUG INFORMATION QUERY
Q. Why Thiamine ( Vit B1 ) is prescribed in alcohol withdrawal
syndrome.
A. Because of chronic intake of alcohol, nutritional deficiency
occurs; hence Vit B1 should be supplemented. Alcohol causes
deficiency of Vit B1 in body. People dependent on alcohol donot
eat properly and can lack certain vitamins. Lack of Vit B1 is most
common which may lead to serious brain damage. Vit B1 may aid
in decreasing fatigue, maintaining mental clarity and maintaining
disorientation. Dose of Vit B1 is 25 mg/ day in alcohol
withdrawal syndrome.