Doorway information about patient
The patient is a 55-year-old man brought in by his wife to discuss ways for him to stop drinking alcohol.
Vital signs
Temperature: 36.7 C (98.0 F)
Blood pressure: 110/70 mm Hg
Pulse: 80/min
Respiratory rate: 14/min

Question

Quizplus · Accepted Answer

The Answer is 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; women: >7 drinks/week or >3 drinks/day)
Impairment in social or occupational function
Legal or social consequences (eg, loss 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 and 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 illnesses.
Differential diagnosis
The differential diagnosis for alcohol use disorder is usually straightforward. However, patients may have additional probems 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, post-traumatic stress disorder, panic disorder)
Chronic insomnia
Personality disorders (eg, antisocial personality disorder)
Dementia
History and physical examination
The initial screen for unhealthy alcohol use can utilize single-item screening, or the AUDIT or AUDIT-C test. The CAGE questions are helpful in further characterizing alcohol use in patients who are positive on the initial screen.

<strong>Approach to the patient</strong> Patients should be evaluated for <strong>unhealthy alcohol use</strong> if they have: <strong>Excessive intake</strong> (men: >14 drinks/week or >4 drinks/day; women: >7 drinks/week or >3 drinks/day) <strong>Impairment</strong> in social or occupational function Legal or social <strong>consequences</strong> (eg, loss of job, arrest for driving while intoxicated) <strong>Adverse health effects</strong> (eg, liver toxicity, resistant hypertension) The evaluation of alcohol use disorders should address <strong>current alcohol intake</strong>, personal and family history of alcohol <strong>abuse and treatment</strong>, and medical and psychological <strong>complications</strong> of alcohol intake. Patients should also be screened for abuse of <strong>other substances</strong> (eg, tobacco, illicit drugs, prescription medications) and for comorbid <strong>psychiatric illnesses</strong>. <strong>Differential diagnosis</strong> The differential diagnosis for alcohol use disorder is usually straightforward. However, patients may have additional probems 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, post-traumatic stress disorder, panic disorder) Chronic insomnia Personality disorders (eg, antisocial personality disorder) Dementia <strong>History and physical examination</strong> The initial screen for unhealthy alcohol use can utilize single-item screening, or the AUDIT or AUDIT-C test. The CAGE questions are helpful in further characterizing alcohol use in patients who are positive on the initial screen. The following sections include additional items that may be useful in evaluation of a patient with alcohol abuse. <strong>Closing the encounter</strong> Patients with alcohol abuse have frequently faced interpersonal conflicts and criticism from family, friends, and coworkers. For this reason, it is essential to convey empathy and use nonjudgmental 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 patients' desire for treatment and provide assurance that you will continue to work with them to address their medical problems. <strong>Diagnostic studies</strong> 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

The following sections include additional items that may be useful in evaluation of a patient with alcohol abuse.

Closing the encounter
Patients with alcohol abuse have frequently faced interpersonal conflicts and criticism from family, friends, and coworkers. For this reason, it is essential to convey empathy and use nonjudgmental 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 patients' 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

Doorway Information About Patient