Clinical Vignette IV

• Which of the following is the most appropriate next step in management of this patient?

A 43-year-old male is evaluated in the emergency department for altered mental status. The patient was brought in by a concerned longtime friend who was with the patient when the 43-year-old male simply “passed out” in the middle of a conversation while drinking an excessive amount of alcohol at the local bar earlier this evening. According to his friend, the 43-year-old male patient has been going through a very difficult divorce and has been spending virtually all of his free time at the same local bar drinking alcohol every evening until he reaches a state of drunken stupor and the bar manager has to call an Uber driver to keep the severely intoxicated man from trying to drive himself home. The next day, the 43-year-old male patient invariably returns to the local bar to retrieve his car keys stating that he has no memory of what happened the prior evening. Per the friend’s report, this uncharacteristic behavior has been a consistent and ongoing issue ever since the 43-year-old patient discovered that his wife filed for a divorce approximately one year ago. Furthermore, the longtime friend states that up until learning about the divorce filing, the patient rarely consumed alcohol, did not smoke, chew tobacco, or use recreational drugs. He also states that there was no visible evidence of trauma when the patient “passed out” earlier today. Unfortunately, due to the patient’s current clinical condition, obtaining a complete history from the patient himself is not possible at the moment which makes the information provided by the longtime friend the best history for the time being. The patient’s electronic medical records reveal that he has a medical history of hypertension, hyperlipidemia, and generalized anxiety disorder. His current medications include lisinopril, simvastatin, and alprazolam.

On physical examination, temperature is 96.2°F (35.6°C), pulse rate is 68 beats/min, blood pressure is 105/65, respiration rate is 12/min, and oxygen saturation is 94% breathing ambient air. There is no gross evidence of trauma but the patient has a strong odor of consistent with recent alcohol consumption. Although limited due to the patient’s current clinical condition, the rest the physical examination is unremarkable. Initial laboratory testing reveals the following:

Serum glucose concentration:  55 mg/dL

Blood alcohol concentration:  279 mg/dL
Urine toxicology screen:  (+) for ethanol and benzodiazepine

• Which of the following is the most likely diagnosis?  

After being evaluated and properly managed by the ED physicians, the 43-year-old male patient was admitted to the inpatient Hospitalist Medicine service for further evaluation and observation. The next day, the patient woke up startled and confused and immediately started asking his nurse all sorts of questions. The nurse immediately paged the patient’s attending physician who showed up very shortly thereafter. Upon arriving in the patient’s room, the attending physician introduced herself and asked if it would be alright if she asked him a few questions. Still appearing confused, the 43-year-old male patient agreed to the physician’s polite request. For the next fiften minutes or so, the physician asked the patient a series of questions and waited patiently for a reply to each question. Throughout the entire series of questioning, the patient seemed generally confused but still tried to provide an answer to each question. The patient was oriented to person but not place or time. When told that he is currently in Medtigo Medical Center, the patient responded by asking what was he doing in a medical center and why was he even there in the first place. The physician then informed the patient about the events that transpired yesterday evening which ultimately prompted his concerned friend to bring him to the Medtigo Medical Center Emergency Department. Still confused and now visibly frustrated, the patient states that he has no memory of any of the events that supposedly happened yesterday evening. He states that the last thing he remembers from yesterday was sitting down at a bar after work to have a drink with his longtime friend. When asked by the physician if he could remember anything else between yesterday evening and now, the patient closed his eyes in an effort to try to remember something but became more visibly frustrated as he was unable to recall absolutely anything. “I guess I must have blacked out, right Doc?” said the patient. The physician responded by asking him how often does he think this happens. After a moment of silent thought, the patient stated that he wasn’t sure. Further questioning revealed that the patient started drinking about a year ago when he discovered that his wife of fifteen years had filed for a divorce and was seeking complete custody of both of their children. Before then, he states that he hardly ever drank alcohol, did not smoke, chew tobacco, or use recreational drugs. He reports that the drinking started out innocuously as a few beers one or two days a week and evidently snowballed out of control over the past year. When asked by the physician, the patient admits that this is a serious problem and that he would like professional help in resolving it.

On physical examination, temperature is 98.3°F (36.8°C), pulse rate is 85 beats/min, blood pressure is 135/82, respiration rate is 16/min, and oxygen saturation is 98% breathing ambient air. Neurologic exam reveals a mild unsteady ataxic gait and horizontal gaze-evoked nystagmus. A Folstein Mini-Mental State Examination reveals a score of 16/30 indicating moderate cognitive impairment. The remainder of the physical examination is unremarkable.

• The 43-year-old male patient states that he wants to quit drinking and has agreed to be treated at medtigo Medical Center’s inpatient rehabilitation wing. During inpatient rehabilitation, the patient will undergo both cognitive behavioral therapy and medication treatment to prevent the possibility of developing alcohol withdrawal. Which of the following is the most likely medication that will be provided to the patient during his inpatient rehabilitation treatment to prevent the possible development of alcohol withdrawal?

• It is commonly observed that chronic alcohol dependence is generally associated with chronic malnutrition which can manifest in a wide variety of clinical findings. One constellation of clinical findings includes the following: megaloblastic macrocytic anemia, hypersegmented neutrophils, pancytopenia, and glossitis. Which of the following vitamin deficiencies is the most likely cause of this particular constellation of clinical findings?