Behavioral Health


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M68_F1.jpg"}},{"insert":"\n\n"},{"insert":"Just yesterday, you treated an unconscious John Doe, who presented with alcoholic ketoacidosis. Thanks to your careful management, he recovered from that acute illness without complications. However, you also found out that he was a chronic alcoholic with numerous problems - his treatment is far from over.\n\nThe story continues now...\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M68_F2.jpg"}},{"insert":"\n\n"},{"insert":"The following day, during your ward round, you learn that \u0022John Doe\u0022 is really Mr. Gideon Shaw, a 45-year-old, former advertising consultant. He says that he has a mild headache and that he feels slightly nauseous and \u0022a bit itchy all over\u0022 as well. No other symptoms are present. He has no recollection of the events last night that lead to his admission to your hospital.\n\nGideon has been drinking heavily for a decade now, averaging between 20 to 30 standard drinks per week, with a tendency to binge-drink. He has been arrested twice for driving under the influence. The second arrest was just two years ago. At that time, his driver\u0027s license was suspended and he was ordered to attend Alcoholics Anonymous (AA) meetings. However, he stopped doing so once the court-mandated period expired.\n\nHe does not smoke and denies abusing recreational drugs. His medical history is without incident, although he states that he has \u0022avoided seeing a doctor for many years now.\u0022 He is not on any medications currently. He has been married for around 10 years now, but is estranged from his wife. He has no children.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M68_F3.jpg"}},{"insert":"\n\n"},{"insert":"On examination, his vital signs are stable. You note flapping tremors with arm extension. The cardio-respiratory examination reveals no abnormalities. Palpation of the abdomen is also unremarkable. The neurological examination reveals bilaterally diminished Achilles tendon reflexes. His gait is normal.\n\nEvaluation of Gideon\u0027s mental state shows him to be alert and oriented to person, place, and purpose. He seems mildly anxious, but is not agitated. There are no thought disturbances. His insight and judgement are intact. He does not appear to at risk of deliberate self-harm.\n\nA review of Gideon\u0027s laboratory studies (including his liver functions, full blood count, and coagulation profile) shows a picture consistent with early alcoholic liver disease. An ultrasound scan is supportive, showing a coarsened hepatic echotexture, without nodularity or features of portal hypertension.\n\nYou ask your intern to calculate his CIWA-Ar score. This amounts to 11 out of 67 points, i.e., moderate withdrawal. Because of this, you start oral diazepam. You also continue the ongoing management for his episode of alcoholic ketoacidosis.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M68_F4.jpg"}},{"insert":"\n\n"},{"insert":"\u0022This is a wake-up call, doctor. I know I can\u0027t do this anymore.\u0022 Gideon states. You feel sorry for him. He clearly has alcohol use disorder, and his drinking has cost him both his job and his marriage.\n\nHow do you plan to manage him in the long run?\n"}]}
1. Brief interventions, including strategies for controlled drinking
2. Intensive interventions, without withdrawal interventions
3. Intensive interventions, including withdrawal interventions