43 year old Chronic Alcoholic with Nausea and Vomiting since 3 days

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A 43 year old police constable from South India , who was apparently healthy 3 days back came to the hospital with complaints of feeling nauseous and episodes of vomiting since then. The vomitings were bilious, about 50-60ml in quantity, yellowish in color, watery in consistency, weren't foul smelling, were non- projectile and weren't associated with blood or food particles. He reports feeling nauseous and vomits even after consuming small amounts of water.

The patient is a known Alcoholic since 20 years. He started consuming alcohol due to pressure from his peers and used to initially consume occasionally about 180 ml of whiskey. Since the last 7 years he's been drinking whiskey daily(about 360 ml which then he gradually increased to about 740ml to 920ml of whiskey(16-20 units). The patient has been consuming alcohol despite the episodes of vomitings for the past 3 days. All these details of his drinking habits were given by his wife. She also reports similar episodes like this that have occurred in the past, for which he took medication from the local pharmacy, the records of which are unavailable. His last drink before presenting to he hospital was the previous day when he had about 180ml of whiskey (4 units). The patient experiences disturbances in sleep during abstinence but denies sweatings, tremors(The wife reports he felt pins and needles on his hands and legs after past binges) and cravings.He also reports to consume alcohol during work hours. His wife reports a h/o blood in stools since 2yrs, the color,quantity etc the details of which were not remembered by either the patient nor his wife. He also gives a history of usage of some herbal medicine locally available to reduce dependance on alcohol.He doesn't abuse any other substances.

The patient gives no history of abdominal pain, constipation or diarrhoea.

The patient gives no history of fever, cold or cough.

The patient gives no history of head injury, blurring of vision, suspicousness, hearing of voices, pervasive low mood, repetitive thoughts and suicidal ideations.

The patient gives no H/O Chest pain, syncopal attacks or palpitations.

The patient had no history of Shortness of breath, orthopnea.

The patient gives no history of burning micturition, urgency or hesitancy.

The patient is not known to be suffering from DM, HTN, Asthma, Epilepsy, TB, CAD.

The patient gives no history of any surgeries performed on him in the past.

He also denies similar complaints being seen in his family. 

He gives no H/O any allergies to food or drug products.

The patient's appetite has decreased significantly since the last 1 week although there's been no change in his diet.

On General examination, the patient was conscious, coherent, co-operative and well oriented to time, place and person.

The vitals: he was afebrile, 

Pulse: 130bpm; B.P.: 110/60mmhg; R.R- 28cpm and Spo2 was 98% on RA.

The patient has no signs of Pallor, Icterus, Cyanosis, clubbing or lymphadenopathy.

There appears to be a pterygium in the left eye of the patient which has just mildly encroached the iris.

MMSE was done where rapport was established and we noted tremors and sustained ETEC. He felt disturbed mentally and on psychiatric consultation was diagnosed to have Alcohol dependance syndrome where he was in withdrawal.

The psychiatrists prescribed the following drugs to him

1.Tab. LORAZEPAM 2mg(1-×-2) for 2 days

2.Inj. OPTINEURON IM/1amp/OD(×-1-×)

Respiratory system: BAE(+) with NVBS and no wheezes or crepts were heard.

CVS: s1,s2 were heard with no murmurs.

GIT: P/A was soft, non tender with no distended veins or organomegaly noted. 

CNS: 

Speech is normal

All cranial nerves are normal

Motor System - power in upper limbs- normal

Lower limbs- power is 4/5 for both flexors and extensors

No wasting of muscles noted

No involuntary movements noted

Sensory system- 

Reflexes- lower limb plantar reflexes are present B/L. B/L absence of ankle, knee and cremasteric reflexes. 

spinothalamic tract - pain - nil

Dorsal column tract - fine touch - normal

vibration- B/L loss of vibration in lower limbs

proprioception normal

cortical sensations are normal on both sides

cerebellar functions are normal

no abnormalities in gait noted

 The following investigations were ordered 

ECG

Hemogram

LFT

RFT

USG

HBsAG 

HIV 1/2 

Anti HCV antibodies

FBS

RFT(2nd day of admission)

LFT(2nd day of admission)

PT

APTT

CBP

2D echo was done which had the following findings: Trivial MR(+), Good LV systolic function, EF=60%  RVSP =30mmhg, no diastolic dysfunction with no PAH and IVC size - 1.25 cms

PLBS was 217 mg/dl 

HbA1c was 7.0 %

Serum LDH was 274 U/L

The following treatment was prescribed to him :

1. IVF 1 pint NS and 1 pint RL@100ml/hr with 1 amp inj.OPTINEURON

2. Inj.THIAMINE 2.5 amps in 100ml NS IV/BD

3. Inj.PAN 40 mg IV/OD

4. Inj. ZOFER 4mg IV/BD

5. Tab. ZINCOVIT PO/OD(×-1-×)

6.Tab. METFORMIN 500mg PO/OD(×-×-1)

7.Tab. LORAZEPAM 2mg 2tabs PO/OD(×-×-2tab)

8. Strict diabetic diet

9. liberal oral fluid intake

10. Absolute alcohol abstinence

After consulting a gastroenterologist, he prescribed additionally 2 more drugs along with the continuation of the above medical treatment i.e.

1.Tab. UDILIV 300 mg PO/BD(1-×-1)

2.Tab. VIBOLIV 500mg PO/BD(1-×-1)

3. Syp. DUPHOLAC 15ml PO/HS

Course in hospital: Patient is subjectively feeling better with respect to his symptoms but objectively there is no improvement in his power with reflexes still being absent.According to his wife, he feels he's been admitted and held for no apparent reason.He also now gives a history of a fracture in his left foot that occurred 1 mnth back which was treated by a cast, the details regarding the mechanism of injury weren't told clearly by the patient. 

Problem representation: A 43yr old Chronic alcoholic presents with Acute Alcoholic Hepatitis(5 points on the Glasgow alcoholic hepatitis score) with alcohol dependance syndrome currently in withdrawal with Denovo DM type 2 and B/L symmetric sensory motor neuropathy.