| | ALCOHOLISM
Doorway information about patient
The patient is a 55-year-old man bought in by his wife to discuss ways for his to stop drinking alcohol
Vital signs
. Temperature : 36.7’ C (98.0F)
. Blood pressure: 110/70 mmHg
. Pulse : 80 /min
. Respiratory rate : 14/min
Approach to the patient
Patients should be evaluated for -unhealthy alcohol use- if they have:
. -Excessive intake- (men>14 drinks /week or > 4 drinks /day ; woman: > 7 drinks/week or > 3 drinks /day)
. -Impairment- in social or occupational function
. Legal or social -consequences- (eg , low of job , arrest for driving while intoxicated)
. -Adverse health effects- (eg, liver toxicity, resistant hypertension)
The evaluation of alcohol use disorders should address -current alcohol intake- , personal and family history of alcohol -abuse and treatment- , and medical any psychological -complications- of alcohol intake . Patients should also be screened for abuse of -other substances- ( eg, tobacco , illicit drugs , prescription medications) and for comorbid -psychiatric illness-.
Different diagnosis
The differential diagnosis for alcohol use disorders is usually straightforward . however , patient amy have additional problems that need to be identified and addressed . the following disorders should be considered when evaluating a patient with alcohol abuse:
. Polysubstance abuse
. Affective disorders (eg,bipolar disorder , major depression)
. Anxiety disorders(eg, pos -traumatic disorder, pain disorder)
. Chronic insomnia
. Personality disorders (eg, antisocial personality disorder)
. Dementia
HISTORY AND PHYSICAL EXAMINATION
The initial screen for unhealthy use can utilize single-item screen , or the AUDIT or AUDIT-C test. the CAGE questions are helpful in further characterizing alcohol use un patients who are positive on the initial screen.
Alcohol use (abuse) screening
1 Single-item screening
. How many times in the past year have you had (5 for men) ( 4 for women) or more drinks in a day?
2 AUDIT-C
. How often do you drink alcohol ?
. How many drinks do you have on a typical day when you are drinking?
. How offend do you have (6 for men) (4 for women) or more drinks on 1 occasion?
3 AUDIT
. 10-items screen assessing frequency , number of drinks &psychosocial consequences
CAGE
. Have you felt you should -Cut down- on your drinking?
. Have others -Annoying - you by criticizing your drinking?
. Have you ever felt bad or -Guilty - about your drinking?
. Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves?
The following section include additional items hat may be useful in evaluation of a patient with alcohol abuse.
History
History of present illness
. At what age did you start drinking alcohol?
. On average , how many drinks do you have in a day? in a week?
. How many days a week do you drink?
. Have you had any mood changes?
. Do you get anxious over small changes ?
. Do you get anxious over small things?
. If you don’t drink for 2-3 days do you get any shakes (tremors)?
. Has you drinking veer gotten you in trouble?
Past medical history
. Have you had any seizures?
. have you had liver problems?
. Do you have high blood pressure ?
Family history
. Do you have any family members with alcohol or drug problems?
Social history
. Are you facing any stressful situations in your home?
. Do you have any financial or occupational problems?
. Do you smoke?
. Do you use recreational drugs?
Review of system
. General : weight changes , change in appetite
. Neurologic : tremors , seizures ,headaches
. Cardiovascular : palpations , rapid heartbeat , high blood pressure
. Gastrointestinal : heartburn m hematuria , melena , abdominal dissension , jaundice
. Psychiatric : depression , anxiety , insomnia
Physical examination
General
. Diaphoresis
. Unusual odor (eg, alcohol , fetor hepaticas , halitosis)
Skin / breast
. Signs of cirrhosis : telangiectasia, jaundice, gynecomastia
Heart
. Tachycardia, ectopy /arrhythmia
Abdomen
. Signs of cirrhosis, ascites , spider angioma , caput medusae
. Hepatomegaly , splenomegaly
Neurologic
. Tremor
. Ataxia /cerebellar dysfunction
Psychiatric
. Impaired level of consciousness
. Anxious or depressed affect
. Increased or decreased psychomotor activity
Closing the encounter
Patient with alcohol abuse have frequently interpersonal conflicts and criticism form family , friends and coworkers . For this reason , it os assertional to convey empathy and use nonjudgemental language when conducting the interview . Adverse findings(eg , signs of cirrhosis ) should be noted and discussed in a straightforward manner , but “lectures “ are rarely helpful . Although treatment and disposition (eg ,admit to alcohol treatment facility) are beyond the scope of the USMLE Step 2 CS exam , you should inquire about patient’s desire for treatment and provide assurance that you will continue to work with them to address their medical problems.
Diagnostic studies
The diagnosis of alcohol use disorder is based on clinical findings . Additional testing is ordered only as necessary to evaluate potential medical complications ( , eg , alcoholic liver disease ) and comorbidities . The following studies should be considered as the individual case warrants:
. CBC
. Hepatic transaminases (AST,ALT, gamma-glutamyltransferase), albumin
. Coagulation markers ( prothrombin time, partial thromboplastin time)
. Hepatitis serologies (hepatitis A,B,C)
. Liver ultrasound
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2018/06/05 10:48pm 
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