Oral Case
Presentation
Krystal Morris
April 12, 2012
 47
year old Caucasian male who presented to the
ED with a chief complaint of “going through a really
bad alcohol withdraw lately.” Three days prior to
coming into the ED, patient began binge drinking,
up to 2L of Vodka per day, his last drink one day
ago. Patient reports that he binge drinks to the
point of blacking out. Patient’s wife found him
minimally responsive yesterday. Throughout the
day, patient became more alert.
 Since
yesterday, the following symptoms have
progressed:
 Sweating, palpitations, nausea, dry heaves,
vomiting. No food or fluid intake for several days.
Patient denies fever, chest pain, chest pressure, no
vomiting frank blood or coffee ground emesis.
Regular bowel movements with no frank blood in
the stools, no black or tarry stools.
 Patient
reports he binge drinks every 1-3 months,
usually for 2-3 days for the past 20 years. Patient’s
wife disagreed with these numbers, stating in the
last year the patient binge drinks 2-3 nights every
week.
 Patient reports that he goes to alcohol support
groups, and his wife states that he really doesn’t go.
20 years ago when binge drinking began, patient
experienced first withdrawal symptoms with some
seizure activity. Patient has been on Librium on a
PRN basis for 20 years. His primary care provider will
currently not prescribe the medication because of
noncompliance issues. He is a 25 pack year smoker.
 Patient
reports difficulty initiating stream and painful
urination. Two weeks ago, patient was seen at a
low income health care clinic in town for urinary
frequency and difficulty initiating a stream,
although he reports that he has always had an
overactive bladder. Urinalysis there was negative
for infection. Prostate exam performed and patient
was told it was enlarged.
 Past
Medical History:
 Bilateral inguinal hernia repair. Patient denies a
history of CVA, CAD, DVT/PE or Diabetes.
Review of Systems

Constitutional: Chills, sweats, fatigue, decreased activity. No fevers.

Eye: Dizziness and vertigo several days ago. Not present at this time.

Ear/Nose/Mouth/Throat: Negative

Respiratory: Negative.

Cardiovascular: Palpitations, no chest pain or heaviness associated with palpitations.

Gastrointestinal: Nausea, vomiting, loss of appetite. No food or drink other than alcohol
for several days.

Genitourinary: Urinary frequency, urinary hesitancy.

Hematology/Lymphatic: negative

Endocrine: negative

Musculoskeletal: Patient reports trips/falls frequently when balance is off from alcohol
consumption

Integumentary: Negative

Neurologic: Alert and oriented x4. Denies headache

Psychiatric: Anxiety, Depression, denies any current suicidal ideations.
Physical Exam

General: Alert and oriented, no acute distress.

Vital signs: Blood pressure: 150/77 (101), heart rate 105, O2 sats 96% on room air, 37.0 TMax

Eye: Pupils are equal, round, and reactive to light

HENT: Normocephalic, atraumatic

Neck: Supple

Respiratory: Lung are clear to auscultation bilaterally. Respirations are non-labored. Breath sounds are
equal. Symmetric chest was expansion.

Cardiovascular: Irregularly irregular rhythm. No murmur, 3+ pulses, equal in all extremities. Capillary refill
<3 seconds.

Gastrointestinal: Normal bowel sounds. No tenderness to light palpation. RUQ tenderness to deep
palpation

Musculoskeletal: Normal full range of motion. 5+ strength in all extremities.

Integumentary: Warm, dry.

Neurologic: Alert, oriented. Normal sensory. Cranial nerves II-XII are grossly intact . No nystagmus or
tremors.

Psychiatric: Cooperative, appropriate mood and affect, non-suicidal.
Building Differential/Working
Diagnosis
 The
patient’s history of alcohol abuse was
the most significant part of his history in
making my differential diagnosis. He had
been heavy binge drinking up to 2L of
vodka per day x3 days. From his basic
symptoms, it was apparent he was
starting to have some withdrawal
symptoms.
Working/Differential Diagnosis

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Closed head injury
 Patient reports blacking out and has a history of falls. Newer abrasion on lip.
Hypovolemia
 Frequent vomiting
 Obtain orthostatic blood pressures to further assess. Start IVF if necessary
Illicit drug abuse
 Based of symptoms of sweating, palpitations
 UDS
 Obtain history from patient and wife
Bipolar Disorder
 Patient’s binge drinking could be a sign of mania follow by low periods when patient
is withdrawing
Pyelonephritis
 Urinary frequency, hesitancy
 Obtain UA. Has patient been having fevers? Flank pain? Blood in urine?
Librium Withdrawal
 Patient usually takes medication for withdraw symptoms, hasn’t been able to obtain a
refill from his primary care physician due to compliance issues.
 Symptoms of withdrawal include sweating, palpitations, tremors
Alcohol Withdrawal
 Patient has been binge drinking several days, history of alcohol abuse
Making the Diagnosis

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Labs were the most significant aspect of the
work-up formulating the final diagnoses
Lab tests ordered: CBC, CMP, PT/INR, Cardiac
Markers, Hgb A1C, toxicology screen,
urinalysis and culture
EKG: Sinus tachycardia with trigeminal
pattern PVCs.
Chest X Ray: Negative on wet read, awaiting
final report
Labs & Diagnostics
CBC &
Differential
WBC 17.8 H
RBC 5.01
Hgb: 15.8
Hct: 43.7%
MCV: 87.2
Platelets: 300
Neutrophils:
76.6% H
Lymphocytes:
13.8% L
CMP
PT/INR
Na: 120 L
K 3.7
Cl: 79
Co2: 21
Glucose: 162H
BUN 23
Creatinine: 1.2
Ca: 10.1
Total Protein:
8.4H
Albumin: 5.1
Alk Phos: 64
AST: 32
ALT: 39
Total Bilirubin:
0.6
Lipase: 23
GFR: >60
Hgb A1C: 5.6%
with estimated
glucose of 114
PT:
12.50
sec
INR:
0.95
Cardiac
Studies
CKMB: 5
Myoglobin:
295H
Troponin:
<.01
CK: 483 H
Toxicology
Screen
Negative for:
Ethanol
Barbituates
Bezodiazepines
Cannaboid
Cocaine
Methadone
Phencyclidine
Oxycodone
Acetaminophen
Amphetamines
Urinalysis
Clarity: Clear
Glucose: Negative
Bilirubin: Negative
Ketones: TRACE
Specific Gravity:
1.020
Blood: MODERATE
amount
PH: 6.0
Protein 100mg/dl H
Nitrates: Negative
WBCS: 12 to 50 H
RBC: 5 to 10
Bacterial FEW
Hyaline Casts: 50 to
100H
Mucous: Present
This UA was then
sent for culture

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Sepsis present on admission

SIRS criteria: WBC >12,000, Tachycardia >90
Alcohol withdrawal

Patient reports binge drinking x3 days. Reporting withdraw symptoms such as chills, diaphoresis, fatigue,
insomnia, anorexia, & palpitations. Start ETOH Withdrawal protocol.
UTI Present on Admission, culture pending

See lab results for abnormal values from culture

Plan of Care: Start IV Rocephin. Once culture is back, make sure organism is susceptible to Rocephin. 1g IV
Q24H.

Abnormalities on UA results indicate a UTI per literature. First line treatment for uncomplicated UTI in men is
Bactrim and Floroquines (Cipro, Levaquin). According to Micromedex 2.0, Rocephin is an appropriate choice
for an uncomplicated UTI. Maximum daily dose is 2g IV. 1g is dosage that is prescribed. Therefore, this
antibiotic is an appropriate choice for this patient.
Hyponatremia

Na: 120

Plan of Care: Monitor Na on Labs. Start NS gtt at 125ml/hr. Monitor for a slow rise in the serum Na. Monitor for
MS changes that can be associated with hyponatremia.
Acute Renal failure

BUN/Creatinine ratio is greater than 20/1 (23/1.2)

Plan of Care: Monitor urine output and lab trends

According to the literature, an increase in serum creatinine >0.5mg/dl above baseline is considered Acute
renal failure. Baseline creatinine was obtained 3 months prior, showing a creatinine of 0.7mg/dl. Creatinine
today is 1.2. This is >0.5 above baseline, therefore can be considered acute renal failure. Volume depletion is
the likely cause for the increase in creatinine. Therefore, volume resuscitation and closely monitoring urine
output is vital to this patient.
Hypochloremia

Cl: 79

Plan of Care: Monitor labs for increase in Cl, likely from vomiting. Plan to stop vomiting through the use of
antiemetics. IVF to help with the volume depletion.
Orthostatic Hypotension due to dehydration

Baseline BP 150/77. Drop in BP from supine to sitting and then sitting to standing

Plan of Care: Bolus 1L NS, start maintenance IVF, NS @ 125ml/hr
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Intractable N/V
 Times several days
 Plan of care: PRN IV Antiemetics and NPO for now, okay to advance as tolerated
Sinus Tachycardia with Trigeminal pattern PVCs
 Per EKG and telemetry monitoring
 Plan of care: Telemetry and electrolyte monitoring. Cardiac enzymes Q6h x3 more draws. Troponin
was <.01, myoglobin elevated
Urinary Frequency
 X2 weeks
 Plan of Care: Started on Rocephin IV which will help with urinary frequency from UTI
Elevated glucose likely to stress response and infection
 Glucose 165 on Chemistry. A1C 5.4%
 Plan of Care: Monitor CBG Q6 hours.
History of Alcohol Abuse
 Several other hospital visits for alcohol abuse. History per patient
 Plan of Care: Psych nurse referral. Social work consult. Pt interested in rehabilitation options
Depression
 Previous suicide attempts x2
 Plan of Care: Psych nurse referral. Pt reports uncontrolled depression with current medication he is
taking
History of Seizures with alcohol withdraw:
 Last seizure 20 years ago. Pt was on Libirum PRN
 Plan of Care: Seizure precautions and high fall risk. Withdraw protocol ordered
It is important to identify
patients with SIRS criteria early.
What are the criteria for
Systemic Inflammatory
Response Syndrome?

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Systemic Inflammatory response syndrome
SIRS criteria states that 2 or more of the following must be present
in order for + criteria:
 Temperature >38.5 or <35
 HR >90
 RR >20 or PaCo2 <32
 WBC >12,000 or <4,000
 >10% immature bands
Sepsis
 Known source on infection must be present. used to properly
diagnosis sepsis along with 2+ of the above SIRS criteria
Severe Sepsis
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At least one of the following signs if hypo perfusion or organ
dysfunction
Areas of mottled skin
Capillary refill >3 seconds
Urine output <0.5 mL/kg for at least one hour, or renal replacement
therapy
Lactate >2
Mental status changes
Platelet count <100,000
DIC
Acute lung injury or acute respiratory distress syndrome (ARDS)
Cardiac dysfunction
Septic shock — Septic shock exists if there is severe sepsis plus one
or both of the following