25 year old male patient with alcohol dependence syndrome

A 25 year old male , daily labour by occupation ,came to the OPD with cheif complaints of -
Head injury since seven days  associated with vomitings, complains of tremors since 2days


History of presenting illness -
patient was apparently asymptomatic 7 days  back then he had head injury (under the influence of alcohol) associated with vomiting since 7days back -1 episode/day projectile,contents-food , tremors developed after stopping alcohol consumption from 2 days

Past history - 
Pateint ia an alcoholic since 1 year which was consumed occassionally then he increased consumption since 3 months because of personal family issues then stopped alcohol consuption from 4 days 
not a known case of htn , dm ,  epilepsy , asthma , tb
no previous surgical history 
no history of gallstones in the past

Personal history :
Diet - mixed ,appetite -decrease appetite ,bowel movement - regular,  bladder movements - regular  , addictions(alcohol) - 
alcoholics in 1 year takes at least 750ml occasional consumption of toody
no history of smoking or chewing tobacco



Family history - 
not significant

On examination -
patient is concious , coherent cooperative
no pallor , icterus , clubbing , cyanosis , lymphadenopathy ,  edema


Vitals - 
Temperature - afebrile 
Pulse rate - 92 bpm 
Blood pressure - 120/90 mm of hg 
Respiratory rate - 22 
Spo2 - 98% at room air


Systemic examination - 
cardiovascular  system : s1 and s2 heard , no murmurs
respiratory system : bilateral air entry present ,normal vesicular breath sounds
central nervous system : nad
p/a - non tender no organomegaly


Investigations
serology- negative

Provisional diagnosis- ALCOHOL DEPENDENCE SYNDROME

Treatment-
IVF NS,RL @ 75 ml/hr
Inj. PAN 40 mg IV OD
Inj. Zofer 4mg IV BD
Inj. Optineuron 1 amp in 100 ml NS IV OD
Inj. Lorazepam 1 amp / 4 mg IM (SOS)
Inj. Thiamine 1 amp in 100 ml NS IV TID
Tab Librium 25 mg 
Tab Baclofen XL 20 mg
Tab  PCM 650 mg PO SOS
Monitor vitals

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