ALCOHOLISM
LEAH GOEDECKE, MS III
CHIEF COMPLAINT
▸ “I can’t keep my balance”
HPI
J is a 69 year old female who presents to the outpatient clinic complaining of imbalance, fatigue, and loss
of feeling in her feet. J states her instability started about 2 years ago and is now almost unbearable. The
frequency of her imbalance she states is all the time with no aggrieving factors. She states her feet have
just been bothering her more recently. She’s sates she feels numbness in her feet that does not radiate
and comes and goes. Sometimes the pain feels like pin pricks and wakes her up at night. Nothing makes
it better or worse. J denies use of NSAIDS or anticoagulants.
J was recently admitted to the hospital from 10-23-18 to 10-26-18 for two days with melena,
hematemesis, epistaxis, weakness and lightheadedness. Associated symptoms were fatigue and
jaundice. J was found to have esophageal varices and portal hypertension gastropathy. J was diagnosed
with alcoholic cirrhosis of the liver which was first diagnosed 4-14-18. The course has been rapidly
progressing. Upon discharge it was noted alcoholic cessation was discussed.
Additionally, J presents with a history of folate-deficiency anemia greater than 6 months. She has noted
fatigue but today denies abdominal or chest pain. J also has a history of biliary cirrhosis.
Today J states her quality of life is decreased because her inability to walk properly and constant fatigue.
J denies anymore drinking after admission to the hospital.
PMH:
▸ Colonoscopy: 2013 (normal)
▸ Bone Density: 2015 (normal)
▸ Mammogram: 2015 (normal)
▸ Pap Smear: 2015 (normal)
▸ Hyperlipidemia 2015
▸ Alcoholic cirrhosis of the liver April 2017
▸ Sever Jaundice August 2016
▸ Ascities May 2017
▸ Anemia of Chronic disease 2017
▸ Hypothyroidism- took Levothyroxin as a teenager
HOSPITALIZATIONS
▸ 4-13-17 TO 4-17-17 -Admitted for lightheadedness and tarry stools;
diagnosed with Jaundice ( scleral icterus), alcoholic cirrhosis of the
liver, and hepatitis.
▸ 5-26-17 TO 5-28-17 - Admitted for generalized abdominal pain;
diagnosed with ascites due to alcoholic cirrhosis, Alcoholic hepatitis,
and jaundice.
▸ 11-23-18 TO 11-26-18- Admitted for hematemesis, epistaxis,
weakness, melena, and lightheadedness; diagnosed with acute blood
loss anemia from upper GI bleeding from esophageal varices and
portal hypertension gastropathy with alcoholic cirrhosis
SURGICAL HISTORY
▸ Appendectomy- Date unknown
▸ Hysterectomy with Bilateral Salpingo-Oophorectomy February 2016
▸ Abdominal paracentesis- May 2017
FH
▸ Father: cause of death prostate cancer
▸ Mother: cause of death skin cancer
▸ Siblings: medical history unknown
▸ Children: 4 ( ages 46,42,39,37) No known health issues
SOCIAL HISTORY
▸ Occupation: retired theatre development
▸ Material Status: Married (Husband is a alcoholic with previous admission
to rehab)
▸ Children: 4 children and 4 step-children
▸ Hobbies: reading, travel, camping, and cooking
▸ Tobacco: Pt. denies
▸ Alcohol: Pt. has history of alcoholism.
▸ Caffeine: Pt. admits to consuming caffeine via tea ( 2 severing per day)
IMMUNIZATIONS
▸ Influenza: was last done 2014, 2015, 2015, 10/2017
▸ Pneumococcal 23: 2014
▸ Shingles: was last done 2014
▸ Tetanus: was last done 2013
ALLERGIES
▸ No Known Drug Allergies
CURRENT MEDICATIONS
▸ Centrum Multivitamin Adults Tablet Take 1 tablet by mouth
daily with food for nutrient deficiency
▸ Spironolactone 25mg Tablet Take 1 tablet by mouth daily for
cirrhosis
▸ Oxybutynin Chloride 5mg Tablet Take1/2 tablet by mouth tid
for urinary incontinence
ROS
▸ Constitutional: Positive for fatigue. Negative for chills, fever, night sweats, unintentional weight gain or
loss.
▸ Eyes: Negative for blurred vision, eye pain, photophobia and double vision.
▸ E/N/T: Negative for diminished hearing, tinnitus, frequent epistaxis, nasal congestion, bleeding gums,
sore throat and tooth pain.
▸ Cardio: Negative for chest pain, claudication, dizziness, palpitations and pedal edema.
▸ Resp: Negative for recent cough, dyspnea, pleuritic chest pain and wheezing.
▸ GI: Negative for abdominal pain, acid reflux, constipation, diarrhea, nausea and vomiting.
▸ GU: Negative for vaginal discharge, dysuria, hematuria and nocturia.
▸ MS: Negative for joint stiffness, limb pain and myalgias.
▸ Neruo: See HPI
▸ Psy: Negative for anxiety, crying spells and depression.
PHYSICAL EXAM
▸ Vitals: 5’ 7”; 150.2 Ibs; BMI: 23.2; T 98.1 F (temporal); BP 115/72 mm Hg ( left arm, sitting) ;
73 bpm; 16 bpm; O2 sat 95% ( room air)
▸ General: well developed; irritably; not well put together
▸ Eyes: sclera-juandice; pale conjuntiva; pupils equal, round, react to light, accommodation
▸ E/N/T: Normal external ears and nose; normal tympanic membrane; normal hearing; normal
nasal mucosa, septum, turbinates and sinus; normal oropharynx
▸ Neck: tracheal position midline; thyroid normal to palpation
▸ Resp: normal respiratory rate and pattern with no distress; persuasion is normal; no rales,
rhonchi, wheezes to rubs
▸ Cardio: normal PMI placement; no thrills, heaves, or lifts; normal rate; regular rhythm; normal
S1 and S2, no S3 or S4; carotids 2+ amplitude, no bruits; abdominal aorta appears to be of
normal size without bruits; 2+ pedal pulses; no edema
PHYSICAL EXAM
▸ GI: normal bowel sounds; no masses palpated; nontender
▸ GU: no bladder or kidney tenderness
▸ Lymph: no enlargement of cervical nodes; bilateral preauricular nodes ( not enlarged);
bilateral posterior auricular nodes ( not enlarged); bilateral supraclavicular nodes (not
enlarged)
▸ MS: No clubbing, cyanosis, or evidence of ischemia; wide-based gait, normal overall
tone; 5/5 strength in all muscle groups; no laxity of any joins
▸ Skin: no skin thickening or subcutaneous nodules; tutor of skin normal
▸ Neuro: CN II-XII grossly intact; reflexes equal; diminished sensation bilateral of the dorsal
and plantar feet; speech normal
▸ Psy: alert and oriented; appropriate affect
REPRESENTATION OF SKIN AND
SCLERA JAUNDICE OF PATIENT
https://www.researchgate.net/figure/Skin-and-sclera-jaundice-of-patient_fig1_283038948
http://www.imrespdx.com/imrespdx-blog/2018/3/14/jaundice-secondary-bacterial-peritonitis
REPRESENTATION OF ABDOMINAL CT
http://www.lumen.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/Ascites.htm
http://www.startradiology.com/internships/general-surgery/abdomen/ct-abdomen-general/
REPRESENTATION OF ENDOSCOPY
https://lazoithelife.wordpress.com/2017/07/24/bleeding-esophageal-varics/
LABS FROM HOSPITAL ADMISSION 1023-18
▸ Ethanol bld equiv BLD Ser Est-mCnc 0.122 [Ref. <0.005
(%)]
▸ Ethanol SerPl-mCnc 122 mg/dL [Ref. 0-5 (mg/dL)]
▸ Hematocrit 26.1 [Ref. 36.0-48.0 (%)]
▸ Hemoglobin 9.2 g/dL [Ref. 12.0-16.0 (g/dL)]
LABS FROM HOSPITAL ADMISSION 1023-18
▸ HEPATIC FUNCTION PANEL
▸ Protein 6.9 g/dL [Ref. 6.1-7.9 (g/dL)]
▸ Albumin 3.2 g/dL [Ref. 3.5-5.0 (g/dL)]
▸ Globulin 3.7 g/dL [Ref. 2.0-3.9 (g/dL)]
▸ Albumin/Globulin 0.9 [Ref. 1.1-2.5]
▸ Bilirub Direct SerPl-mCnc 1.6
▸ Bilirubin 3.1 mg/dL [Ref. 0.4-2.0 (mg/dL)]
▸ Alkaline phosphate 151 IU/L [Ref. 38-126 (IU/L)]
▸ Aspartate aminotransferase 135 IU/L [Ref. 150-41 (IU/L)]
▸ Alanine aminotransferase 39 IU/L [Ref. 14-54 (IU/L)]
“In viral hepatitis, alcoholic liver disease and in primary biliary
cirrhosis (PSC) , the ratio of aspartate to alanine
aminotransferase (AST/ALT) has been proven to be an indicator
of liver cirrhosis…An AST/ALT ratio >/=1 is significantly
associated with the presence of cirrhosis and poor outcome in
PSC.” J’s lab indicated an AST/ALT ratio of 3.4+ indicating a
strong presence of cirrhosis and PSC.
https://www.ncbi.nlm.nih.gov/pubmed/17498256
LABS FROM OFFICE 11-21-18
▸ CBC Differential, w/Platelet
▸ WBC 5.9 k/mm3 (Ref. 4.0-11.0)
▸ RBC 2.93 m/mm3 (Ref. 3.70-5.40)
▸ Hemoglobin 9.1 g/dL (Ref. 11.5-16.0)
▸ Hematocrit 30.4 % (Ref. 35.0-48.0)
▸ MCV 31.1 pg (Ref. 78.0-100.0)
▸ MCH 31.1 pg (Ref. 27.0-34.0)
▸ MCHC 29.0 g/dL (Ref. 31.0-37.0)
▸ Platelet Count 270 k/mm3 (Ref. 130-450)
LABS FROM OFFICE 11-21-18
▸ Ferritin 16 ng/mL (Ref. 11-307)
▸ Vitamin B12 956 pg/mL (Ref. 232-1245)
▸ Folate 11.3 ng/mL (Ref. >=4.0)
▸ Iron 21 ug/dL (Ref. 35-175)
▸ TIBC 400 ug/dL (Ref. 250-400)
▸ % Sat. 5% (Ref. 15-50)
LABS FROM OFFICE 11-21-18
▸ Comprehensive Metabolic Panel (Fasting)
▸ Glucose 124 mg/dL ( Ref. 65-99)
▸ BUN 10 mg/dL (Ref. 8-25)
▸ Creatinine 0.58 mg/dL (Ref. 0.60-1.40)
▸ GFR Estimated 94 mL/min/1.73m2 (Ref. >=61)
▸ Sodium 135 mmol/L (Ref. 134-147)
▸ Potassium 4.1 mmol/L (Ref. 3.6-5.3)
▸ Albumin 3.9 g/dL (Ref. 3.4-4.9)
▸ Globulin 3.6 g/dL (Ref. 2.0-3.7)
▸ Alkaline Phosphatase 110 IU/L (Ref. 42-146)
▸ Alanine Aminotransferase 23 IU/L (Ref. 5-41)
▸ Aspartate Aminotransferase 53 IU/L (Ref. 10-41)
▸ Bilirubin, total 0.8 mg/dL (Ref. 0.2-1.3)
ASSESSMENT
▸ Acute alcoholic hepatitis
▸ Alcoholic cirrhosis of the liver
▸ Folate-deficiency anemia
▸ Gait instability
▸ Alcoholic Neuropathy
PLAN
▸ Acute alcoholic hepatitis
▸ Discuss cessation of consumption of alcohol including removal of alcohol from home, avoid time with other
drinkers, suggestion of AA group or referral to psychiatry, suggestion of alcoholic rehabilitation
▸ Alcoholic cirrhosis of the liver
▸ Discuss cessation of consumption of alcohol, suggestion of AA group or referral to psychiatry, suggestion of
alcoholic rehabilitation
▸ Folate-deficiency anemia
▸ Supplement with Folate acid daily, Thiamin 100 mg daily and Vitamin B12 1000 MCG daily
▸ Gait instability
▸ Referral to initiate physical therapy
▸ Alcoholic Neuropathy
▸ Discuss cessation of consumption of alcohol, check feet for ulcerations
DISCUSSION
▸ Alcoholism is known have a strong genetic
factor, in fact an offspring to a parent with
alcoholism is four times more likely to
develop alcoholic behaviors. Use of
alcohol in people with a predisposition
causes a marked increase in release of
Beta-endorphins in the dopamine reward
pathway that goes from the ventral
segmental area to the nucleus accumbent
and prefrontal cortex. Alcohol may
stimulate the reward pathway to cause the
alcoholic to feel “normal” compared to
those with normal brain chemistry.
Alcoholic cerebellar degeneration; atrophy of superior
portion of the vermis
DISCUSSION
▸ Chronic alcohol use can cause malnutrition
by stimulating acid production causing
severe erosive gastritis. This new GI
environment makes it difficult for the body to
absorb nutrients and vitamins. One vitamin
particularly important for the brain to
metabolize glucose to produce energy is
thiamine. One reversible thiamine deficiency
encephalopathy is known as Wernicke.
Patients usually present with paralysis of eye
muscle, ataxia, confusion and/or acute
psychosis. Korsakoff follows untreated
Wenicke’s and presents with short term
memory disturbances and confabulation.
Korsakoff is irreversible.
https://nurseslabs.com/nursing-health-assessment-mnemonics-tips/
DISCUSSION
▸ Alcohol can also be toxic to the nerve
tissue causing axonal death that begins
distally. This is known as
polyneuropathy; symmetric deficits in the
nerves that begin in the feet and ascend
( proximal progression). Patients can
present with arm and leg numbness,
tingling, burning, prickly sensations,
muscle weakness and movement
disorders. Nerve damage from this
condition is usually permanent and
symptoms are likely to get worse if the
patient does not stop drinking.
SOURCES
▸ https://www.healthline.com/health/alcoholism/alcoholicneuropathy#prevention
▸ https://medlineplus.gov/alcoholismandalcoholabuse.html