Development
After the initial laboratory
studies the patient was placed on a specific treatment regimen
which resulted in the gradual decrease of his abdominal pain. On
the second hospital day, the patient became increasingly agitated
voicing concerns about his practice and his patients, and
indicated the need to leave the hospital to care for his patients.
Fellow physicians had arranged to cover his patients, but the
patient became increasingly adamant about leaving the hospital.
During the evening of the third day he complained about people
talking to him from the hallway, and was yelling at nursing
attendants as if they were all friends from his past. That same
evening he became concerned about animals in his room and appeared
to believe that he was at home in his own room. On the fourth
hospital day, his confusion seemed to be lifting somewhat and he
was more aware of his surroundings but responded slowly and
hesitantly to questions. The fifth and sixth hospital days saw a
continued clearing of his mental state.
Q2: As this case developed,
what was the initial complication?
1. Perforation of the bowel
/A: Wrong! There is no evidence of bowel perforation 2.
Diabetes /A: Wrong! There is no evidence of diabetes 3.
Alcohol withdrawal /A: Correct! there is clear evidence for
this complication
Q3: Which of the findings
were helpful in making the diagnosis of alcohol withdrawal?
1. WBC: 18 000 /A: This is not very helpful. The WBC will go
up in pancreatitis from any etiology and doesn't really
further the diagnosis of alcohol withdrawal. 2. Bruises and
burns on hands /A: This is a useful response although not
confirmatory. These are frequently found in alcoholics and
result in part from falling asleep while smoking after heavy
drinking. These changes are the first hint at the presence
of alcohol problems. 3. BAL: 200mg% /A: Certainly an
important response. This indicates a tolerance for alcohol,
since the patient wasn't obviously intoxicated on admission,
and therefore warns of the likelihood of alcohol withdrawal
complications. 4. MCV: 110 (normal 87) /A: Very important.
The elevation in the MCV is proving to be an extremely
important indicator of alcohol problems. 5. Agitation and
confusion /A: Very good! The agitation alone could be due to
a number of psychological stresses he faces but when coupled
with confusion, the presence of organic brain syndrome
becomes more certain. 6. Decreased vibratory and position
sense /A: This is a good response, as it is frequently
present in alcoholic deterioration. However, it is also
present in nutritional disorders, so that in itself it is
supportive but not definitive. 7. Flushed and tremulous /A:
Very good response. The distinct tremor of the alcoholic in
withdrawal can be particularly demonstrated when the patient
is asked to protrude his tongue. 8. Concern about his
practice /A: Although it seems inappropriate in this
situation, there are many possible explanations. Therefore,
it doesn't really help your diagnosis of withdrawal. 9.
Serum amylase 100 /A: Indeed this bolsters your diagnosis of
pancreatitis but does nothing to further your database of a
diagnosis of alcohol withdrawal. 10. Hallucinations
(auditory and visual) /A: Fine! These are certainly
hallmarks of alcohol withdrawal, but with your increasing
level of sophistication you'll see only those patients of
your colleagues who do not recognize alcohol withdrawal
early. Your patient will be early and adequately medicated
so that you will seldom see this late sign of withdrawal.
Hospital course 2 Well
done, you have made the correct diagnosis and treated
effectively but further complications developed on the
eighth hospital day which led to concern about other drug
use and prompted closed questioning of his wife. During the
eighth hospital day, the nurse on the unit noticed that he
appeared more distressed, was walking about a good deal, and
complained of muscle cramps. While she was checking his
blood pressure he experienced a grand mal seizure with tonic
contractions of all extremities, incontinence of urine, and
a mild laceration of the tongue. Neurological exam revealed
no focal abnormalities.
Further history elicited
from his wife following this episode revealed that the
patient had been in the habit of taking a variety of
tranquilizing medication which he self-prescribed to quiet
his stomach. His wife further indicated reluctantly that he
had been arrested 1 month PTA for driving while intoxicated.
A breathalyzer test at that time revealed a BAC of 230 mg%,
but he was released with only a warning because of his good
position in the community.
Q4: Which of the following
were factors which figured in your suspicion that the
patients has been also taking tranquilizers? 1. Grand mal
seizure /Good. Seizures are the most dangerous complication
of withdrawal from sedative type medications, and are
particularly relevant in an individual who is also
withdrawing from alcohol. 2. Agitation /Good. You certainly
wonder about the uncovering of an underlying agitative
depression, but it is early for that, an uncomplicated
alcohol withdrawal doesn't usually show this activity. 3.
Muscle cramp /Fine. These are fairly common in patients
withdrawing from the benzodiazepines. 4. Delayed appearance
of symptoms /Very good. This late appearance of withdrawal
symptoms of the sedative-type tranquilizers often catches
clinicians by surprise, especially when they plan an early
discharge from the hospital. 5. Absence of localizing
symptoms /Accurate. The seizure may give you concern about a
subdural hematoma, so frequent in alcoholics, but the
absence of localizing symptoms may make it less likely.
However, you would follow up with other studies to be
certain. 6. High incidence in the population /Excellent!
Physicians who are alcoholics are frequently dually
addicted, and your alertness to this type of information can
be very important.
Q. With the diagnosis of
alcohol and drug withdrawal properly established how would
you treat this acute problem: 1) Antabus /Wrong. 2)
Benzodiazepines /Yes, multiple oral loadings of diazepam
until reasonable symptomatic relief.. Tapering of
tranquizers according to the clinical picture. 3) Thiamin
/Yes 4) Fluids, glucose. /Yes; May require correction of
electrolytes.
Q8 The following agents are
currently available as "pharmacological" treatment
of chronic alcoholism:
1. Naloxone /Good! FDA
recently approved naloxone as the first pharmacological
adjuvant in alcoholism treatment. It decreases alcohol
intake relapse (see figures and tables, from Volpicelli et
al, J Clin Psychiatry 56 (suppl 7): 39, 1995) The mechanism
of action of naloxone in alcoholics is based on endogenous
opioid hypothesis: alcohol ingestion stimulates the release
of endogenous opioids which increases rewarding effects of
alcohol through opiates rewarding system. Mu/d opiate
blockers would block this mechanism of reinforcement. animal
and human studeis confrimed the hypothesis.. Important to
recognize that pharmacotherapy without other interventions
is not effective. Self-supporting groups, such as Alcoholic
Anonymous, had more success than any other approach so far.
2. Antabuse /This aversive type of therapy has come out of
favour primarily because of its ineffectiveness 3.
Bromocriptine /This is an experimental drug, not approved
for regular use. Several clinical trials in the past 10
years suggested positive but short lasting effect of
bromocriptine on drinking behaviour. Hypothetical mechanism
of action: bromocriptine as an agonist at the dopaminergic
reward system would suppress craving for alcohol and thus
decreasing drinking.
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