42 Male Alcoholic came to De-addiction centre

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

42 male businesses man by occupation resident of Haliya brought with complaints of :

Alcohol consumption since 10 days(increased consumption since 5 days - 2 full bottles per day

Background History:

Consuming alcohol since 15 yrs started with arrak and toddy gradually shifted to whiskey.reports consumes alcohol since 10-15 days  approx.2 full bottles/day stopped due to force of family members 1-2 yrs.patient was completely abstinent for an year till last 10 days.

HOPI: 

Patient was apparently asymptomatic 10 days ago then started drinking beer in a family function due to family and peer influence then continued drinking approx. 2-3 bottles of beer/day shifted to whiskey since 5 days ago and gradually started consuming upto 2 bottles per day.Reporta consumed 1 bottle yesterday due to gastric discomfort and approx.360ml today morning at 6 am.

Experiences sleep disturbances, palpitations,anxiety if he doesn't consumes alcohol.

Desire to consume alcohol present.

Not going to work since 10 days.

Consumes Alcohol knowing it's harmful effects

Reports continued consuming alcohol due to intense desire to consume alcohol and withdrawal symptoms.

No other substance abuse

No h/o head injury,seizures,loss of consciousness 

No h/o blood on stools and vomitus

No h/o pervasive low mood , suicidality

No h/o grandiosity and flight of ideas

No h/o repetitive thoughts and actions

No h/o hearing of voices self talking behaviour 

Currently complaining of epigastric pain and nausea.

Past history:

H/o DAC admission in kims narketpally 10 yrs ago

H/o HTN since 2yrs and on regular medication 

Not a k/c/o  DM,Asthma, Epilepsy,CVA,CAD, thyroid disorders 

No h/o other psychiatric illness in the past

Family history:

Attender reports his whole family of patient consumes alcohol including his father,mother,4 sisters and 3 brothers

Personal history:

Sleep-Normal

Appetite-decreased since 3 days due to nausea

Bowel and bladder movements - regular 

General Examination:

Patient is drowsy,co operative 

Moderately built and nourished

No pallor, icterus, cyanosis clubbing,Lymphadenopathy and edema 

Vitals:

BP:110/70mm Hg

PR:88bpm

RR:18cpm

Spo2:98% on RA

Temp: 97.3

MSE(Mental status examination):

Patient is lying on bed comfortably , responding appropriately to oral commands, slightly drowsy and giving approximate answers, occasionally slightly restless and agitated 

ETEC(Eye to eye contact)-positive and sustained 

PMA(psychomotor agitation)-slightly increased

Speech- normal, relevant and coherent 

Thought -cravings for alcohol present

Mood- Andholanagaundi

Affect- slightly agitated 

Perception -NAD

Oriented to time, place and person

Systemic Examination:

CVS:

Jvp not raised 

Inspection:

Shape of chest - elliptical

No visible pulsations

No engorged veins and scars 

Apical impulse not visible

Palpation:

Apex beat present over the left 5th intercostal space 1cm medial to midclavicular line

No parasternal heave

No precordial thrill

No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

Respiratory system:

Upper respiratory tract - normal

Lower respiratory tract-

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- Midline

Palpation:

Trachea is Midline

Normal chest movements

Vocal fremitus is normal in all areas 

Percussion: in sitting postion

                            Rt.                Lt

Supraclavicular. N(resonant).  N

Infraclavicular. N         N

Mammary region. N.    N

Axillary region. N.       N

Infra axillary region. N.    N

Supra scapular region. N.    N

Interscapular region. N.    N.  

Infrascapular region. N.    N

Auscultation:

Normal vesicular breath sounds

No added sounds

Vocal resonance is normal in all areas

CNS :

Higher motor functions - intact

Cranial nerves - intact

Motor system:

            Rt- UL. LL.            Lt- UL. LL

Bulk - normal N.            N. N

Tone - N. N.                  N. N

Power - 5/5. 5/5.          5/5. 5/5

Reflexes:         

                       UL             LL

Biceps. 2+.       2+

Triceps. 2+. 2+

Supinator. 2+. 2+

Knee 2+. 2+

Ankle. 2+. 2+

Plantar-flexion flexion

Sensory system: intact

Co ordination is present 

Gait is normal

No Cerebellar signs 

No signs of meningeal irritation 

Per Abdomen:

Inspection:

Shape - scaphoid 

Umbilicus - inverted

All quadrants moves equally with respiration 

Palpation:

All inspectory findings are confirmed 

No local rise of temperature

Abdomen is soft and non tender 

spleen and liver -not palpable 

No other palpable masses

Hernial orifice are free

Percussion:Resonant

Auscultation:

Bowel sounds heard

Investigations:

Provisional diagnosis:

Alcohol dependence syndrome 

Treatment Given:

1.TAB LORAZEPAM 2MG PO/TID

2.TAB BACLOFEN XL 20MG PO/BD

3.TAB PREGABALIN M 75MG PO/OD

4.TAB BENFOTHIAMINE 100MG PO/BD