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Case Presentation

Reason for admission


Mr.NR , a 47-year-old Indian gentleman ,
known case of alcoholic liver disease
Child Pugh C , was admitted to HTAN
due to left lower limb swelling of 1 week
duration diagnosed as cellulitis.
He was referred to the psychiatric team for
alcohol dependence

Alcohol History
Started drinking alcohol at the age of 20 due to peer
pressure.
His last drink was in September (two months ago).
Prior to that , he had been drinking 2 3 bottles (1/4
litres) of samsu a day for almost 30 years. Denies
increased consumption.
Continued to drink despite knowledge of his medical
condition.
Easily upset or angry when his wife refused to give him
money to buy alcohol.
Craving or strong desire to drink no successful
attempts to cut down

Continued

Withdrawal symptoms ???


Depression ???
Anxiety ???
No hallucinations / delusions
No suicidal ideation
Denies any history of substance abuse.
Claims having good relationships with his wife and
children.
Currently unemployed due to his poor health. Used
to work as a rubber tapper.

Past Medical / Psychiatric History


Diagnosed with alcoholic liver disease Child
Pugh score C in year 2013 fluid restriction
, spironolactone. Not compliant to his
medication and defaulted his follow-up visit.
No previous admissions to psychiatric
ward.
Never sought treatment for his alcohol
dependence.

Family History
No family history of psychiatric illnesses
Both his parents passed away due to old
age.

Social History
Lives with his wife and three children in
Bahau, Negeri Sembilan.
Currently unemployed stopped working
because of health reasons.
Does not smoke.

CAGE questionnaire

Mental State Examination


Well-groomed , dressed in hospital gown
Calm , not agitated though appeared slightly
lethargic / sleepy at times.
Good eye contact
Euthymic
No suicidal ideation
Speech coherent and relevant
Denies any forms of delusions, hallucinations
or illusions

Oriented to time , place and person.


Memory is intact
Attention and concentration not impaired
Insight he is aware of his current
problem alcohol dependence , wishes to
quit drinking.

Physical Examination
Vital signs stable
Not pale or jaundiced
Clubbing , palmar erythema , scleral
icterus , gynaecomastia , bilateral pedal
oedema
Abdomen is distended liver & spleen not
palpable
Cerebellar examination normal

10. Tolerance, as defined by either of the following:


a. A need for markedly increased amounts of alcohol
to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of
the same amount of alcohol.
11. Withdrawal, as manifested by either of the
following:
a. The characteristic withdrawal syndrome for alcohol
(refer to Criteria A and B of the criteria set for alcohol
withdrawal, pp. 235236).
b. Alcohol (or a closely related substance, such as a
benzodiazepine) is taken to relieve or avoid
withdrawal symptoms.