General Information

A 58-year-old African American man goes to see his doctor for routine follow-up for hypertension and heartburn (symptoms of gastroesophageal reflux disease [GERD]).

During the visit, he completes a screening for alcohol use, which yields a positive result. His score on the CAGE alcohol screen is 2+, which indicates alcohol dependence. He reports that he has cut down from previous drinking levels and that his wife is annoyed with his drinking. He does not think his drinking is a big problem.

The patient has a family history of alcohol dependence: His mother was alcohol dependent and died of cirrhosis.

Patient Profile

The patient is a 58-year-old African American man. He is a lawyer with his own practice. He is happily married with two adult children.

The patient presents with a complaint of GERD symptoms, which he has treated unsuccessfully with an over-the-counter antacid (Tums). The patient is concerned that he may be developing an ulcer because of the high stress level associated with his job and family finances. During the interview, the patient tests positive on a screening for alcohol use known as the CAGE alcohol screen (refer to box below), indicating he may have a drinking problem. The patient is slightly defensive when talking about his alcohol use, but overall he is comfortable with the interview and maintains good eye contact.

Past Medical History

The patient's medical history is significant for a leg fracture suffered 5 years ago when he fell from a ladder while hanging holiday decorations. The patient notes that he was intoxicated at the time. He has had hypertension for 8 years, for which he takes medication and maintains a low-salt diet.

Habits

• Exercise : patient exercises 5 times a week, including a 2- to 3-mile early morning run
• Smoking history : nonsmoker
• Drug use : none
• Alcohol use : 2-3 drinks at lunch, 6-7 drinks at night to help him unwind; no history of alcohol treatment
• Positive result on screening for alcohol use, with answers as follows:
  • CAGE score: 2+ ("cut down" and "annoyed")
    • C : Yes. When the patient was young, he used to drink a lot more, especially on weekends. The patient does not want to risk hurting his liver, as his mother did. He recalls how painful her last year was, with ascites and major bleeding episodes. He has tried to cut down even more, but says, "It takes more than a few drinks to fully relax."
    • A : Yes. The patient gets annoyed when his wife and children bug him about his drinking. He thinks they do not fully understand how much stress his job causes.
    • G : No. He does not feel guilty about his drinking.
    • E : No. The patient never drinks before noon on workdays, but may have an early beer when working around the house on weekends.

Family history

• Father : hypertension, suffered heart attack at age 70
• Mother : alcohol dependence, died of cirrhosis at age 65

Visit Summary

The patient and his doctor are discussing the patient's complaint of heartburn. In the course of assessing this patient, the doctor has discovered that the patient has a high level of alcohol intake. The doctor is concerned because the amount of alcohol the patient is drinking is unhealthy, and it probably is worsening his heartburn symptoms and increasing his blood pressure.

Assessment

The interview starts with the doctor summarizing her concerns about the patient's drinking.

"You are correct to worry about the possible negative effects that alcohol can have on your body. In fact, alcohol could be the cause of your GERD and high blood pressure . . ."

The doctor then asks the patient a series of questions. (The patient's responses appear in bold face.)

"You said you have cut down on your drinking; was this in the past year?" "Yes."

"Can you tell me more about that?"

• "I was worried that the alcohol could be hurting my liver. You know my mother died of cirrhosis. . . . What a terrible way to go. . . . I am very concerned about my health. . . . You know, I work out every morning before work."
• "A physician in an ER (treating my leg fracture) once told me to try going to an AA meeting, but I told him I resented the assertion that I was an alcoholic. . . . I grew up with an alcoholic. . . I know an alcoholic when I see one. . . . He apparently didn't realize that I am a successful lawyer and in great physical shape."
• "Now, my mother was a real alcoholic because she drank at home alone and started every day with a highball. . . . She would black out from drinking, and eventually died of cirrhosis. . . . At least I can control my drinking."

"You said your family expressed concerned about your drinking. Did that take place within the past year?" "Yes."

"Can you tell me more about that?"

• "My wife and son have told me that I drink too much and that they don't like the way I act when I'm drinking. But they don't understand how stressful my work is. . . . Everyone needs to find a way to unwind. . . . don't you think, doc?"
• "When my son was a teenager, he once told me that he was embarrassed to invite his friends over the house on days when I was drinking because I get too loud. . . . That really hurt. . . . Imagine your son being embarrassed of you?"

"You state that 7 drinks isn't too much for you."

• "I can hold my liquor because I have a very high tolerance. . . . It must be in the genes. . . . I have never blacked out, and the next day, I always remember what I did."

Feedback

• The doctor expresses concern about the patient's health and the likelihood that the amount he drinks is affecting his health. The doctor discusses the possible connection between the patient's alcohol intake and his GERD symptoms and elevated blood pressure.
• The doctor recommends that the patient start taking medication for his heartburn symptoms, and the patient agrees.
• The doctor points out that 10 drinks per day on most days is a lot more than 90% of the U.S. adult population admits to consuming. "We know that drinking this much puts your health at risk and is also probably increasing your heartburn symptoms." The patient indicates that he would be willing to cut down his drinking to help his Heartburn and his general health.

Advise and Assist

The doctor expresses concern about the patient's current level of drinking and recognizes that it may be difficult for the patient to change his habits. She reviews the link between alcohol and his health and recommends that he abstain from drinking because he is consuming alcohol at dangerous levels. "The best course is to stop drinking. As your doctor, that is what I would recommend. If you do not want to stop drinking, then cutting down to no more than 4 drinks per occasion and no more than 14 drinks a week would be a safer level. What do you think you want to do?"

• The patient states that he has "no problem" with stopping his drinking but enjoys the relaxed feeling he gets while drinking, and therefore he agrees to the goal of drinking no more than 4 drinks on an occasion and no more than 14 drinks a week.

The doctor then asks, "Are you ready to change your drinking habits?"

• The patient replies that he is, and he thinks he could be successful in cutting down to below recommended limits.

The doctor is supportive of his choice to cut down. "What you've decided is a great step toward maintaining your good health."

The doctor mentions that the patient should give her a call if he does not feel well when he decreases his drinking, but the patient expresses confidence that he will be fine, as he has abstained from drinking for several days in the past and not had a problem. The doctor also mentions that, if the patient is interested in support groups, other patients have found Alcoholics Anonymous very helpful. However, the patient states that he is not interested because he does not want to listen to strangers tell their stories, and he is afraid he will encounter someone he knows.

Arrange Follow-Up

The patient agrees to return in 2 weeks to check on how his blood pressure and GERD symptoms respond to his cutting back on drinking.