Return to Scenario ListShow Learning Points most relevant to Phase 1:

Alcohol and drug dependence disorders

Clinical Discipline(s)/Organ System(s)
Psychiatry/Health Psychology, Emergency Medicine, Digestive System, Gastroenterology & Hepatology, Neurology
Progress Test Topic(s)
Mental health
A 54 year old NZ European male, recently separated from his wife, is a general surgeon working at a large metropolitan hospital. He also has a part-time private practice. He is seen in the Emergency Department with a history of having arrived at a work-related social event earlier in the evening in a 'slightly intoxicated' state, and then being found collapsed and comatose in the male toilets two hours later. A colleague called an ambulance. On examination, he has an impaired Glasgow Coma Score of 12 while no neurological localising signs are detected. His breath smells of alcohol and alcohol blood levels are twice the driving limit (160 mg/dL). His blood glucose is normal. There is no paracetamol in his blood and urine toxicology results for other drug metabolites are negative. His estranged wife, who is the next of kin identified on his medical records, confirms that he drinks heavily. She reports that, as of late, he has started his first glass of wine in the morning, 'to steady his nerves'. On average, he drinks about two bottles of white or red wine per night. His drinking increases on weekends, and at these times he often becomes inebriated. His busy work schedule and heavy drinking patterns resulted in their recent separation. They remain amicable however, and his wife has encouraged him to seek help for his drinking. You go to see him after he regains consciousness and start to discuss his drinking habits.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Current biopsychosocial theories of the aetiology of alcohol and substance dependence
   - Pathology of alcoholic liver disease
   - Pathology of Wernicke/Korsakoff syndrome; role of thiamine deficiency
   - Pharmacology of ethanol including toxicity, hypnosedatives (e.g. benzodiazepines, chlomethiazole), cannabis, opioids, amphetamines, cocaine, LSD, MDMA ('ecstasy')
   - Misuse of drugs
   - Pathophysiology of alcoholic dementia, especially frontal lobe
   - Awareness of nutritional deficiencies and how this may compound certain presentations e.g. delirium tremens
Clinical and Communication Skills 
   - Elicit a history from a patient with substance abuse or a collateral history from a colleague, screen for underlying mental illness
   - Perform a mental state examination of a patient with substance abuse; when patient is sober, perform assessment of cognitive impairment in relation to memory and frontal lobe function
   - Neurological examination of a patient with reduced level of consciousness; calculate Glasgow Coma Score
   - Perform a risk assessment for harm to self or others; assess suicide and neglect risk
   - Use 'CAGE' tool to screen for alcohol abuse and apply more detailed assessments such as the Alcohol Use Disorders Identification Test (AUDIT) and Edwards and Gross criteria for dependence
   - Screen for other comorbid drug use such as over the counter medication, prescribed medication (hypnotics, analgesia), accessible drugs (aftershave, antiseptic hand gels, medicine cabinets on wards) and illicit drugs
   - Apply criteria for assessing withdrawal from alcohol e.g. CIWA-Ar (Clinical Institute Withdrawal Assessement for Alcohol)
   - Motivational interviewing techniques
   - Interpret relevant investigations: electrolytes, blood glucose, hormonal screening, thiamine and B12 levels, toxicology screen, imaging
   - Differential diagnosis of substance abuse or alcohol dependence
   - Management of acute intoxication or overdose (general and specific treatments); management of withdrawal, including delirium tremens
   - Management of dependence: pharmacological, psychological, and other non-biological methods
   - Complications of alcohol and substances of abuse (including intravenous drug abuse)
   - Awareness of high mortality rates with delirium tremens and the medical treatments required for this
   - Awareness of common co-existing disorders, e.g. depression, anxiety, personality problems
Personal and Professional Skills 
   - Competence and consent
   - Confidentiality and privacy
   - Motor vehicle licensing regulations
   - Non-judgemental approach to mental illness
   - Social impact of mental illness
   - Showing empathy
   - Responding to professional problems of colleagues
   - Impaired colleague; roles and responsibilities
   - The aggressive patient
   - Power dynamics regarding the interaction between this consultant and yourself
   - Self-care
   - Role of Medical Council of New Zealand
Population Health 
   - Epidemiology of alcohol abuse
   - Epidemiology of other substance abuse
   - High risk populations and occupations
Conditions to be considered relating to this scenario
alcohol abuse/dependence, social phobia, panic disorder, insomnia, dysthymic disorder, depression, bipolar affective disorder, anxiety disorder, opioid abuse, benzodiazepine and other hypnosedative abuse/dependence, cannabis abuse, obstructive sleep apnoea, hyperthyroidism, Wernicke-Korsakoff syndrome, alcoholic hallucinosis, MDMA (ecstasy) abuse, opioid abuse, amphetamine abuse, cocaine abuse/overdose
Less common but 'important not to miss'
encephalitis, meningitis, systemic lupus erythematosus (SLE), brain tumour, intracranial haemorrhage, hypercalcaemia, encephalopathy of any cause, head trauma, pancreatitis, subdural haemorrhage
Lyme disease, HIV, infective endocarditis
Related Scenarios
[Self-harm], [Alcohol]