OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: NUNEZ, JUANCHO Age/Sex: 45/M Address: Port Area Manila Date of admission: August 4, 2007 Admitting Diagnosis: Alcohol Withdrawal Syndrome Alcoholic Liver Disease HCVD, NSR, NIF Residents in charge: Drs. Aguila.Receno/Dimaandal Intern-in-Charge: Ryan Escandor Clerk-in-Charge: Palay/Rentillo/Roxas
Hospital #: 1717731
24 hour history This is a case of a 45 year-old male who came in due to increase in sleeping time History of Present Illness Patient is a heavy alcoholic drinker consuming 4-5 bottles per day for the last 15 years. Patient allegedly stopped drinking alcohol since two weeks ago. He was apparently well until.. 2 days PTA, patient had tremors of hans and increased sleeping time. No fever, no cough , no chest pain, no seizure noted. No consult done Few Hrs PTA, persistence of above condition with changes in behavior with disorientation and irritability prompted consult. Hence the admission. Past Medical History (+) HPN x 10 years Family History (+) HPN mother side Personal and Social History Occasional smoker and an alcoholic beverage drinker, 4-5 red horse beer of about 500mleach bottle/day and with history of illicit drug use (metamphetamine) one year ago. Review of Systems Constitutional: (-) anorexia, (-) weight loss HEENT: (+) BOV, (-) tinnitus Respiratory: (-) cough (-) colds (-) hemoptysis Cardiovascular: (-) easy fatigability, no chest pain Physical Examination: Drowsy, confused, irritable, not in distress Vital Signs: BP: 140/80 HR: 102 RR: 20 Temp: 36.9 HEENT: pink palpebral conjunctivae, anicteric sclerae, no mass, no neck vein engorgement, no nasoaural discharge, no cervical lymphadenopathies CHEST AND LUNGS: symmetrical chest expansion, - retraction, no lags, clear breath sounds HEART: adynamic precordium, no heaves, no thrills, PMI at 4th ICS AAL, NRRR, no murmur ABDOMEN: flat, normoactive bowel sound, soft, non tender, no mass (+) scar on right upper abdomen, non tender EXTREMITIES: full equal pulses, no edema, no cyanosis NEUROLOGIC: disoriented (+) flight of ideas CN l – NA Il – PERTLA 2-3mm III, IV, VI – Intact EOM V – (+) bicorneal reflex VII – no facial asymmetry VIII – NA IX X- good gag XI – NA XII - NA
Assessment: Alcohol Withdrawal Syndrome Alcoholic Liver Disease HCVD, NSR, NIF PLAN: For admission
Patient was admitted under the service of Drs. Gardaya/Changco/Aguila/Receno/Dimaandal. NGT was maintained. He was hooked to IVF: PNSS 1L with 1 amp Vit B complex x 8 hours. Diagnostic procedure requested were CBC with platelet count, urina lysis, CXRPA, 12-L ECG, serum albumin, PT PTT, SGOT, SGPT, Alk PO4, FBS, BUN, crea, Na, K, HDL, LDL, TG, Chole, BUA, Blood CS/ Sputum GS/CS, Sputum AFB. Medications were Diazepam 1 amp TIV q6, Vitamin B complex amp TID. He is placed on a moderate to high back rest. Request for responsible 24 hour watcher at bedside. Patient was restrained. To watch out for changes in sensorium. VS monitored q1 NVSq1 CBGq6. Course in the wards Upon admission, vital signs were stable. NGT was ordered to be requested however the patient refused. PT and PTT was requested. Other labs were were still requested VS q2 and NVS with CBG q6. to watch out for active seizure and checheduled for hemodialysis. Still on moderate to high back rest with VS monitored q2. WOF uremic ssx, dyspnea, cyanosis. On the 1 hospital day, NGT was still ordered to be inserted. OF feeding was ordered to start with 2100 kcal in 3 divided meal. IVF to follow: PNSS 1L with Vitamins B amp x 8 hours for whole abd’l UTZ. Continue meds. Placed on a moderate to high back re st and to ensure 24 hour responsible watcher at bed side. To WOF change in sensorium and combative behavior. VS monitored q2, NVS q2. I and O monitoring. CBG AC/HS. On close watch. At around 6:50 pm, NGT was still ordered to be inserted. OF feeding was still ordered once NGT inserted. IVF to follow: PNSS 1L with Vitamins B amp x 8 hours for whole abd’l UTZ. Continue meds. Placed on a moderate to high back rest and to ensure 24 hour responsible watcher at bed side. To WOF change in sensorium and combative behavior. VS monitored q2, NVS q2. I and O monitori ng. CBG AC/HS. On close watch.