HISTORY
The patient is a 47-year-old male who was brought in by
ambulance after his wife said he had a seizure at 4:30 this morning in the
bed. She thinks he might have had 2 more
before that but did not recognize what they were. He has never done this before. She states he has been having problems and
going to South Baldwin Hospital on Wednesday and Thursday night. I asked her what were the problems; he had
stomach pain, nausea, vomiting and his potassium was low. She states they gave him IV fluids and potassium,
but he got more tremulous every time, and she said she gave them a history that
he used to have a drinking problem, but he drinks occasionally. She is not particularly sure, she is just his
significant other, and she can tell you whether he is drinking at all. She does know that he has not been able to
drink really because of his stomach hurting.
I asked they did he throw up any blood, and she said no, it was just all
kind of bile at the end and no diarrhea.
When he had the seizure, she called the ambulance, and he was brought
into the hospital. In the emergency
room, he had an elevated heart rate of 100, his blood pressure was 160/106,
respiratory rate was 20. He was worked
up in the ER. He underwent a CT scan of
the head. They were going to try getting
an ultrasound of the abdomen because of the elevated liver function tests but
were unable to complete secondary to agitation.
The ER doctor thought he was in early ETOH withdrawal. He was transferred up to the ICU. I was called secondary to being on unattached
call. By the time I got up to the
unattached ICU, they called me within 2 hours, this gentleman is in full blown
DTs, he is hallucinating. He is
agitated, has an escalated heart rate, escalated blood pressure. He is combative and he is just nonstop
motion. I came in to see him at
approximately 1:00 p.m. and patient was yelling, screaming, wanting help. His significant other had just left the room. He wanted her to come back because he was
confused. I did a positive string test;
he said his string is gray and he is in Foley and someone needs to cut these
lines off his arms; he is in restraints.
PAST MEDICAL HISTORY
Obtained mainly from the significant other who is not the
best historian because they have only been together for a year, and evidently
he has been kind of secretive with all his problems to her, but she knows a
lot.
ALLERGIES
He has no known allergies.
MEDICATIONS
He is on no chronic medication. He was on methadone up until 3-1/2 weeks ago;
she knows that. He was being weaned from
120. He had been weaned down to 90
milligrams and he discontinued it because he wants to get into the VA program
where there is some new pain medicine that is not addicting and he can use, but
he has to be off methadone, so he stopped it cold turkey. She also states she is not sure the last time
he drank. He sneaks it around because
she does not like him drinking because of his liver disorder. I asked her what that was. He has hepatitis C. He also has a history of Hodgkin
lymphoma. He said he was treated in the
1980s for that; she said a year and a half ago through the VA, and I am not
sure who is right. She also says he has
polycythemia vera and they have to watch his iron count. He evidently was in Desert Storm as well, and
how much of this is true from how much of what he is telling me I do not
know. He is unable to give me any
straight answers at this time.
Evidently, he is legally blind in his left eye.
FAMILY HISTORY
At this time is noncontributory.
SOCIAL HISTORY
He and she is unsure of his last alcohol use, but said he
used to be on crack drugs and lots of different narcotics, but he has not used
any crack or stuff like that within 8 years.
He has had left arm surgery in the past and a vasectomy and that is
about all she knows. He does smoke about
a pack a day and has been for years. He
had dental work done on Tuesday where they pulled his bottom teeth, and they
put on amoxicillin for that and Mepergan.
She said he only took 2 or 3 Mepergan; they were too strong and worried
about his liver, so they switched him to Lortab #12, 5 milligrams and he has
taken all those in the last 3 days, but interestingly, when we did his opiate
level, it was normal.
OBJECTIVE
GENERAL/VITAL SIGNS:
When I see patient, his blood pressure is 168/112. He is yelling, screaming. His heart rate is 109. He said he wants to be cut loose, and he is
in back yard in Foley. He has visual
hallucinations with a positive string test.
He said the string is gray, but it changes.
ENT: His pupils are
equal, round and reactive to light but he will not let you do much else because
he starts telling me to leave him alone.
When you can calm him down and talk to him, he is somewhat distractible,
but still very upset.
CHEST: He has
bilateral breath sounds, some rhonchi.
CARDIAC: Tachycardic
rhythm. It is hard to tell if he has any
murmur because he just keeps yelling.
ABDOMEN: Soft but he
says it has been hurting for the last few days and no one has done a damn thing
about it.
RECTAL: Did not
attempt exam at this time.
EXTREMITIES: No
edema.
LABORATORY DATA
On admission, his acetaminophen level is less than 10. His opiates are negative. His blood alcohol is less than 5. His urinalysis shows 1+ blood, trace ketones,
no white cells, no red cells. CBC showed
a white count of 8.3. His H and H is
13.4 and 39.2. Magnesium is 2.5. His electrolytes plus - his sodium is 133,
potassium is 2.4. His bilirubin is
3.1. His alk phos is 80. His SGOT is 150, SGPT is 79. His INR is 1.
Lipase is 91, slightly elevated.
His amylase is 86. CT scan of the
head was reported as normal. They were
unable to get the ultrasound evidently.
Chest x-ray was reported as normal.
His EKG shows a normal sinus rhythm with some baseline artifact, no
prolongation of the QT interval.
ADMISSION DIAGNOSES
1. Delirium
tremens, full blown.
2. Ethanol
withdrawal.
3. Questionable
opiate withdrawal, but he was given Dilaudid and it did not really make a
difference, and he had already had 0 opiates in his urine, which I found
strange since she said he has been taking Lortab.
4. Nausea
and vomiting.
5. Epigastric
pain.
6. Hypokalemia.
7. History
of Hodgkin lymphoma.
8. Hepatitis
C.
PLAN
At this time, will use universal precautions. He is going to be on a CIWA protocol. He was given some Haldol to try controlling
the agitation. I also gave him 0.1 of
clonidine and I placed him on a 0.3 clonidine patch. The Haldol so far has helped some but not
significantly. We are going to try him
on Geodon after a significant time period.
He has had replacement of his potassium with potassium jump, and we are
going to repeat that and repeat his electrolytes. Also will repeat his lipase and amylase because
there is a chance he could have pancreatitis, especially with alcohol drinking,
which I think is significantly more than reported. I have talked with his significant other that
he has 10% to 15% chance of mortality with him being in full blown DTs and he
has probably been going through alcohol withdrawal for the last 2 to 3 days,
and that is why she has been seeing him shake and tremble and throw up. She is going to relay that to his mother and
he evidently has 3 grown kids in Birmingham.
I have discussed with her that he might have to wind up on a ventilator
and intubated if unable to control.
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