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S.K. is a 34 year old male who presented to the emergency department on 9/5/2019 with severe abdominal pain that has worsened over the past few days & nausea/vomiting that gets worse after eating.

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Hypertension

Cardiomyopathy

Depression

Alcohol and drug abuse

Smoking (1/2 pack per day)

Lives at home with mom, dad, and brother

Installs ceramic tile for income

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Denies weight changes

Complains of nausea/vomiting

Denies headache

Complains of sweating

Denies problems with joints & muscles

Denies problems with urination

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Assessment Findings from 9/6/2019 at 10am

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Assessment Findings from 9/6/2019 at 10am

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Alert and oriented to person, place, and time
Vital signs: 98.1 F, 104bpm, 140/98, 20, 96% on room air.

Patient complains of pain in upper left quadrant.  He describes it as sharp and aching and rates it 9-10/10.  Movement and eating makes it worse.  Specifically notes that his frequent hiccups cause increase pain in his abdomen.  Rest and morphine improve the pain slightly.  Severe nausea accompanies the pain and he has vommitted a few times.

Abdomen soft, flat, and non-distended.  Bowel sounds active.  Tympanic sounds over abdomen and dullness in left upper quadrant.  Tenderness present in left upper quadrant, but no guarding noted. No hepatomegaly or ascites.

Skin is pale with light pink undertones throughout.  Skin moist and intact, beads of sweat visible on forehead.  No edema noted in bilateral lower extremities.

Patient able to ambulate independently.  Denies visual, auditory, and tactile disturbances.  No tremors notes.

Respirations regular, shallow depth, and labored on room air.  States it is hard to take a deep breath due to the abdominal pain.  Lung sounds clear but slightly diminished in bilateral lower lobes.

Patient denies chest pain, palpitations, and dizziness at this time. No lifts, heaves, or thrills.  Apical rate 102.  S1 and S2 audible but faint.  Telemetry rhythm is normal sinus rhythm with periods of tachycardia.

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No known allergies

Bupropion 150mg twice a day

Carvedilol 3.125mg twice a day

Lisinopril 5mg daily

Levothyroxine 25mcg daily

Venlafaxine 75mg daily

Rosuvastatin 10mg daily

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CT of Abdomen:

Pancreas low density and diffusely enlarged

Extensive peripancreatic fat stranding and adjacent fluid

Mild fatty liver

Acute pancreatitiswith surrounding peripancreatic inflammatory changes

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Calculate a score using the link.  Retrieved from https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal#creator-insights

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Advice

Benzodiazepines are generally used to control psychomotor agitation and prevent progression to more severe withdrawal.

Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are the most frequently used benzodiazepines. Follow your hospital's own alcohol withdrawal protocol; frequently treatment begins with benzodiazepines when CIWA-Ar scores reach 8-10, with standing or as needed dosing for scores 10-20. Some protocols even include transfer to the ICU for scores >20.

Consider additional supportive care, including intravenous fluids, nutritional supplementation, and frequent clinical reassessment including vital signs.

Management

Assessment protocols utilizing CIWA-Ar vary and include medication dosing triggered by symptoms only and combined symptom-triggered + fixed-dose medication dosing.

Critical Actions

Other conditions can mimic or coexist with alcohol withdrawal, including:

Drug overdose

Trauma (eg, intracranial hemorrhage)

Infection (eg, meningitis)

Metabolic derangements

Hepatic failure

Gastrointestinal bleeding

Consider additional testing to rule out alternative diagnoses, especially if presentation includes altered mental status and/or fever.

Have feedback about this calculator?

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Benzodiazepines are generally used to control psychomotor agitation and prevent progression to more severe withdrawal. Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are the most frequently used benzodiazepines. Follow your hospital's own alcohol withdrawal protocol; frequently treatment begins with benzodiazepines when CIWA-Ar scores reach 8-10, with standing or as needed dosing for scores 10-20.

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Acute Alcoholic Pancreatitis

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What symptom commonly presents with both alcohol withdrawal and pancreatitis?

a.    Nausea & vomiting

b.    Hypoxia

c.    Epigastric pain

d.    Visual disturbances

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Which one of the following is not the role of the CNS in managing a patient with pancreatitis?

a.     Coach nursing staff on reflective listening.

b.     Administer pain medications to a patient with a pain score of 8/10.

c.     Recommend alternative pharmacological treatment options based on the best evidence available.

d.     Offer patient education on diagnosis and disease management to the patient.