Thought content: Incoherent,

confused, delusional

Perception Illusions, hallucinations No change

Judgment Poor Poor, socially inappropriate

Substance Abuse Disorder (Alcohol)

Alcohol dependence syndrome

(A definite diagnosis of dependence should usually be made only if three or more of the

following have been present together at some time during the previous year)

A strong desire or sense of compulsion to take the substance.

Difficulties in controlling substance-taking behavior in terms of its onset, termination, or

levels of use.

A physiological withdrawal state when substance use has ceased or been reduced.

Evidence of tolerance, such that increased doses of the psychoactive substance are

required in order to achieve effects originally produced by lower doses.

Progressive neglect of alternative pleasures or interests because of psychoactive

substance use.

Persisting with substance use despite clear evidence of overtly harmful consequences,

such as harm to the liver through excessive drinking.

CAGE questionnaire

Affirmative answers to any two of the following questions (or to the last question alone) are

suggestive of alcohol abuse.

Have you ever felt that you should cut down your drinking?

Have you ever felt annoyed by others criticizing your drinking?

Have you ever felt guilty about your drinking?

Have you ever had a morning drink (Eye-opener) after hangover?

Table 9.5 presents consequences of alcohol misuse and dependence.

Table 9.5: Consequences of alcohol misuse.

Acute alcohol intoxication Features of alcohol withdrawal

syndrome

Disturbances in emotional and behavioral state Psychological: Restlessness, anxiety,

panic attacks

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

–

–

–

–

•

–

–

Medical symptoms: Due to hypoglycemia,

aspiration of vomit, respiratory depression

Complication of other medical problems

Accidents, injuries developed in fights

Autonomic: Tachycardia, sweating,

pupil dilatation, nausea, vomiting

Delirium tremens: Agitation,

hallucinations, illusions, delusions

Seizures

Table 9.6 presents consequences of harmful alcohol use. consequences

of harmful alcohol use.

Table 9.6: Consequences of harmful alcohol use.

1. Medical

Neurological: Peripheral neuropathy, dementia, cerebral hemorrhage, cerebellar

degeneration, Marchiafava-Bignami syndrome, subacute combined degeneration of the

cord myopathy, ventricular enlargement and cognitive impairment.

Hepatic: Fatty change and cirrhosis, hepatocellular carcinoma

Gastrointestinal: Esophagitis, esophageal varices, Mallory-Weiss syndrome, esophageal

carcinoma, gastritis, malabsorption, pancreatitis, parotid enlargement

Skin: Palmar erythema, spider naevi, Dupuytren’s contractures, telangiectasias

Cardiac: Cardiomyopathy, hypertension

Respiratory: Pneumonia, tuberculosis

Musculoskeletal: Myopathy, fractures

Endocrine and metabolic: Pseudo-Cushing’s syndrome, hypoglycemia, gout

Reproductive: Hypogonadism, infertility, fetal alcohol syndrome

2. Psychiatric and cerebral

Depression

Alcoholic hallucinosis

Alcoholic ‘blackouts’

Wernicke’s encephalopathy:

Nystagmus

Ophthalmoplegia

Ataxia

Confusion

Korsakoff’s syndrome

Short-term memory deficits

Confabulation

1.

a.

b.

c.

d.

e.

2.

a.

b.

Semilong Cases

C H A P T E R

10

SEMILONG/THERAPEUTIC CASES

Therapeutic cases are common cases that will be encountered in

outpatient settings. In examination of such cases, candidate is

expected to take a brief focused history, do general examination and

relevant systemic examination pertaining to the case. Also, the

candidate is expected to formulate a management plan for the patient

which would include relevant investigations, treatment strategy, and

appropriate referral.

Common therapeutic cases kept are diabetes mellitus (DM),

chronic kidney disease, thyroid disorders (hypothyroid/hyperthyroid),

obesity, hypertension (HTN), fever, chronic obstructive pulmonary

disease (COPD), bronchial asthma, anemia, pedal edema, and

anasarca.

The format of case taking would include following:

History:

Demographic details and presenting complaints

Duration of disease and presence of complications

Treatment details, any surgeries/interventions, and history of

hospitalizations

Personal history

Diet history

General physical examination:

Vitals

Anthropometry

3.

a.

b.

c.

d.

e.

f.

4.

5.

6.

•

•

•

•

•

•

•

•

Systemic examination:

Skin

Cardiovascular

Respiratory

Neurological

Gastrointestinal

Musculoskeletal

Complete diagnosis

Investigations

Treatment plan.

A: Diabetes Mellitus

History Type of diabetes

Duration

Any complications—microvascular/macrovascular

Other coexistent diseases—hypertension, etc.

Treatment history

Diet history

Family history

History of hypoglycemia

Vitals Pulse—peripheral pulses, resting tachycardia, and vessel wall

thickening

Hypertension and postural hypotension

Raised jugular venous pressure (JVP)

Pedal edema (renal, cardiac, insulin induced, and autonomic

neuropathy)

Anthropometry Body mass index (BMI), waist circumference, and waist-hip ratio

Skin Ulcers

Signs of insulin resistance (acanthosis nigricans, skin tags, and

visceral obesity)

Diabetic dermopathy (shin spots) and blisters

Taenia, intertrigo, balanoposthitis (Figs. 10A.1 and 2),

vulvovaginitis, oral thrush, folliculitis, and carbuncle

Cardiovascular Orthostatic hypotension, resting tachycardia, evidence of

hypertension, and heart failure

Respiratory Pneumonia and tuberculosis

Neurological Polyneuropathy and autonomic dysfunction Retinopathy (Figs.

10A.3 and 4)

Gastrointestinal Gastroparesis, constipation, and nocturnal diarrhea

Musculoskeletal Carpal tunnel syndrome, diabetic Cheiroarthropathy, Charcot’s

joint, frozen shoulder, and Dupuytren’s contracture

Others Genitourinary—urinary incontinence, recurrent infection,

impotence, erectile dysfunction, and retrograde ejaculation

Examination of foot—ulcers, callosities, and vascular and

neurological examination

Complete

diagnosis

For example, type 2 diabetes mellitus with hypertension and

obesity with nonproliferative retinopathy, chronic symmetrical

sensorimotor polyneuropathy with autonomic dysfunction

Investigations Hemoglobin A1c (HbA1c), fasting blood sugar (FBS), postprandial

blood sugar (PPBS), serum creatinine, fasting lipid profile, urine

routine and microalbuminuria, electrocardiogram (ECG), and

thyroid stimulating hormone (TSH)

Treatment plan Nutritional and lifestyle modification

Drugs including insulin

Management of complication

Referral Ophthalmology, nephrology, and neurology

Fig. 10A.1: Intertrigo.

Fig. 10A.2: Balanoposthitis.

Fig. 10A.3: Nonproliferative diabetic retinopathy.

Fig. 10A.4: Proliferative diabetic retinopathy.

B: Hypertension

History Duration

Complications

Treatment details

Vitals Signs of atherosclerosis (vessel thickening, bruits, and

xanthelasma)

Peripheral pulses and radio-femoral delay—coarctation

Pulse rate and rhythm

Blood pressure (BP) to be checked in all four limbs and postural BP

Edema (cardiac, renal, and drug induced)

Pallor [chronic kidney disease (CKD)]

Anthropometry BMI and waist-hip ratio

Skin Hyperpigmentation, striae, signs of CKD, and thyroid disease

Cardiovascular Signs of left ventricular hypertrophy (LVH) (heaving apex, S4) and

heart failure

Respiratory Obstructive sleep apnea (OSA)

Neurological Fundus—hypertensive retinopathy

Evidence of stroke

Renal Palpable kidney (polycystic kidney) and renal bruit (renal artery

stenosis).

Complete

diagnosis

Hypertension (primary/secondary) with LVH and retinopathy (Fig.

10B.1)

Investigations ECG, creatinine, urine routine and protein, echocardiography, FBS,

lipid profile, serum uric acid, and evaluation of secondary causes—

thyroid, ultrasonography (USG) abdomen

Treatment plan Nutritional and lifestyle modification

Drugs

Management of complication

Referral Ophthalmology and nephrology

Fig. 10B.1: Fundus image of hypertensive retinopathy.

C: Chronic Kidney Disease (Fig. 10C.1)

History Duration

Treatment details and dialysis

History for etiology—DM, HTN, drugs, chronic glomerulonephritis,

etc.

Symptoms of uremia

Vitals Hypertension, pallor, edema, and raised JVP

Anthropometry BMI

Skin Pruritus/itching, rash, uremic frost, metastatic calcification,

arteriovenous (AV) fistula (Fig. 10C.2) and dialysis catheter

Cardiovascular Atherosclerosis, heart failure, hypertension, and pericarditis

Respiratory Pulmonary edema, pleural effusion, and interstitial lung disease

Neurological Peripheral neuropathy, encephalopathy, proximal myopathy,

seizures, myoclonic twitching, coma, and restless leg syndrome

Gastrointestinal Loss of appetite (anorexia), nausea, vomiting, diarrhea, GI bleed

Musculoskeletal Bone pains

Others Women: Amenorrhea and menorrhagia

Males: Erectile dysfunction and oligospermia

Complete

diagnosis

For example, chronic kidney disease (stage—) secondary to

diabetes, and patient has peripheral neuropathy

Investigations Serum creatinine, urea, electrolytes, arterial blood gas (ABG),

ECG, ECHO, ultrasound abdomen, urine analysis, and complete

blood count (CBC) with peripheral smear

Treatment plan Nutritional and lifestyle modification

Drugs

Medical management

Hemodialysis

Referral Nephrology

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