Identifying Data
Initials: J.R.
Age: 21
Race: Black (Non-Hispanic)
Gender: Male
Height: 5’10”
Weight: 158lbs
Subjective Data
Chief Complaint:
Nausea, vomiting and dry heaves related to alcohol withdrawal. Increased depression, suicidal ideations, auditory and visual hallucinations.
History of Present Illness
The patient is a 21-year-old single African American male with a past medical history of depression, attention deficit hyperactivity disorder and ETOH abuse. The patient presents to the ER after a 12 day drinking binge for acute alcohol withdrawal. Patient states he had been sober for six months, but relapsed after his …show more content…
Thyrotoxicosis: Known as “thyroid storm”, this disease is the result of heavy amounts of thyroid hormone being dumped into the blood stream. It’s associated with undiagnosed hyperthyroidism. Without immediate medical attention this condition is fatal. Symptoms include increased body temperature, tachycardia, nausea, vomiting, diarrhea, confusion, seizures and abdominal …show more content…
Meningitis: Meningitis is the inflammation of the meninges; the membranes that surround the brain. This disease can be caused bacteria, viruses, drug reactions, head injury, cancer or tuberculosis. Symptoms include fever, headache, irritability, nausea, vomiting and/or change in mental health status. Assessment
Based on patient history, lab results and physical assessment “alcohol dependence with delirium tremens” is the most rational diagnosis. Alcohol is a CNS depressant that encourages relaxation and geniality. It is a fixture in American society, a part of recreational activities, celebrations and even religious ceremonies. However, it is a mind altering substance that can have deadly consequences especially for those who become addicted.
In the US 45-50% of adults are “current” drinkers; 20% “former” drinkers with 30-35% never drinking (lifetime abstainers). Of the “drinking” population, It is estimated that 5-10% struggle with alcohol addiction. The Center for Disease Control state that alcohol is the most widely abused substance in our culture.
Plan
I. Patient and Family
Initials: J.R.
Age: 21
Race: Black (Non-Hispanic)
Gender: Male
Height: 5’10”
Weight: 158lbs
Subjective Data
Chief Complaint:
Nausea, vomiting and dry heaves related to alcohol withdrawal. Increased depression, suicidal ideations, auditory and visual hallucinations.
History of Present Illness
The patient is a 21-year-old single African American male with a past medical history of depression, attention deficit hyperactivity disorder and ETOH abuse. The patient presents to the ER after a 12 day drinking binge for acute alcohol withdrawal. Patient states he had been sober for six months, but relapsed after his …show more content…
Thyrotoxicosis: Known as “thyroid storm”, this disease is the result of heavy amounts of thyroid hormone being dumped into the blood stream. It’s associated with undiagnosed hyperthyroidism. Without immediate medical attention this condition is fatal. Symptoms include increased body temperature, tachycardia, nausea, vomiting, diarrhea, confusion, seizures and abdominal …show more content…
Meningitis: Meningitis is the inflammation of the meninges; the membranes that surround the brain. This disease can be caused bacteria, viruses, drug reactions, head injury, cancer or tuberculosis. Symptoms include fever, headache, irritability, nausea, vomiting and/or change in mental health status. Assessment
Based on patient history, lab results and physical assessment “alcohol dependence with delirium tremens” is the most rational diagnosis. Alcohol is a CNS depressant that encourages relaxation and geniality. It is a fixture in American society, a part of recreational activities, celebrations and even religious ceremonies. However, it is a mind altering substance that can have deadly consequences especially for those who become addicted.
In the US 45-50% of adults are “current” drinkers; 20% “former” drinkers with 30-35% never drinking (lifetime abstainers). Of the “drinking” population, It is estimated that 5-10% struggle with alcohol addiction. The Center for Disease Control state that alcohol is the most widely abused substance in our culture.
Plan
I. Patient and Family