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The oncall physician is called to see a 46 y/o male patient because of seizures. The patient was admitted to the surgical ward 2 days ago, after emergency trauma surgery. The nurse reports that the patient was anxious, irritable and tachycardic last night. Later on, the nurse noted nausea, diarrhea, sweating and insomnia. The pt has tremors, startle response and hallucinations earlier tonight

Vitals
T 99
p133
BP 146/89
RR 22
O SAR 92%

You have already ordered physical exam

Gen: sweating, cigarette burns on hands, multiple tattoos and rings
Chest: wnl
Abdomen: hepatomegaly
neuro: tremors, confusion, delirium, clouded sensorium, evidence of peripheral neuropathy

Lets start with what can be the differential dx in this patient?

I thought of some sort of withdrawl, hypoxia, infection that could cause delirium. You guys can be more specific.
THIS IS A CASE OF ALCOHOL WITHDRAWL.

After physical exam, we will order the following

IV ACCESS
SALINE
CARDIAC MONITOR
CBC
BMP
CA
MG
VITAMIN B12 LEVEL
PHOSPHATE
LFTs
EKG
TSH
URINALYSIS
URINE TOXICOLOGY SCREEN
ABGS
CXR
ATIVAN ONE DOSE NOW AND Q 2-4 HOUR IV
THIAMINE
FOLIC ACID
GLUCOSE ( IF LOW, GIVE DEXTROSE IV)
FOR BLOOD PRESSURE, WE CAN ADD ATENOLOL
FOR AGITATION, WE CAN ADD SOME HALDOL IM/IV NOW AND REPEAT AS NEEDED

INTERVAL HISTORY
IF PATIENT SEEMS STABLE, MOVE TO ICU

ADMISSION ORDERS:
BES REST
NPO
URINE INPUT OUTPUT
CHECK BMP Q 24 HR
VITALS Q 2 HRS

INTERVAL HISTORY: IF PATIENT GETS BETTER, MOVE THE CLOCK TO NEXT DAY ROUNDS

INTERVAL HISTORY NEXT DAY. PATIENT FEELS BETTER
DC IV FLUIDS
DC NPO
START REGULAR DIET
DC IV MEDS
START PO LIBRIUM
START ATENOLOL PO, IF NEEDED

COUNSEL (EVERYTHING THATS NEEDED)
ALCOHOL ANONYMOUS
CONSULT SOCIAL WORK

FOLLOW UP IN 2 WEEKS

DX
ALCOHOL WITHDRAWL


in terms of DDX

CNS: Delirium
Resp: PE
CVS: ??
GIT/Metabolic: Hep encephalopathy - he has hep C risk factors which could progress to cirrhosis and HE
Alcohol withdrawl
Electrolyte imbalance - hypo or hypernatremia
Toxic ingestion

First stabilize
ABCDE

Airway - sat 92% - place on pulse oximetery and give oxygen
B - Oxygen
C - tachy with hTN = D51/2NS contimue Cardiac monitor

Now some stat labs
ABG - on all hypoxic patients
CBC - look for macrocytic anemia
Metabolic panel 14 will give you LFT and everything
accucheck for glucose
CXR
EKG r/o arrythmias
UA toxo screen

Now PE

next step :
Thiamine followed by dextrose
Naloxone

Diazepam

re assess pt in 30 min
add haloperidol if pt is agitated

all pts with alt mental status transfer to ICU