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Toronto Notes 2019 Common Presenting Problems
Assessment
• screenforalcoholdependencewithCAGEquestionnaire
■ if CAGE positive, explore with further questions for alcohol abuse/dependence
• assessdrinkingprofile
■ setting, time, place, occasion, with whom ■ impact on: family, work, social
■ quantity-frequency history
◆ how many drinks per day?
◆ how many days per week?
◆ maximum number of drinks on any one day in the past month?
• ifidentifiedpositiveforalcoholproblem
■ screen for other drug use
■ identify medical/psychiatric complications
■ ask about drinking and driving
■ ask about past recovery attempts and current readiness for change
Investigations
• GGTandMCVforbaselineandfollow-upmonitoring
• AST,ALT(usuallyAST:ALTapproaches2:1inanalcoholic)
• CBC(anemia,thrombocytopenia),INR(decreasedclottingfactorproductionbyliver)
Management
• interventionshouldbeconsistentwithpatient’smotivationforchange
• individualizedcounsellingandregularfollow-upiscrucial
• 10%ofpatientsinalcoholwithdrawalwillhaveseizuresordeliriumtremens • AlcoholicsAnonymous/12-stepprogram
■ outpatient/day programs for those with chronic, resistant problems
■ family treatment (Al-Anon, Alateen, screen for spouse/child abuse) • in-patientprogramif:
■ dangerous or highly unstable home environment
■ severe medical/psychiatric problem
■ addiction to drug that may require in-patient detoxification ■ refractory to other treatment programs
• pharmacologic
■ diazepamforwithdrawal
■ disulfiram (Antabuse®): impairs metabolism of alcohol by blocking conversion of acetaldehyde to
acetic acid, leading to flushing, headache, N/V, hypotension if alcohol is ingested (available in U.S.,
but no longer available in Canada)
■ naltrexone: competitive opioid antagonist that reduces cravings and pleasurable effects of drinking
◆ may trigger withdrawal in opioid-dependent patients
■ acamprosate: glutamate receptor modulator that also reduces craving
• seePsychiatry,PS23
Prognosis
• relapseiscommonandshouldnotbeviewedasfailure
• monitorregularlyforsignsofrelapse
• 25-30%ofabusersexhibitspontaneousimprovementover1yr
• 60-70%ofindividualswithjobsandfamilieshaveanimprovedqualityoflife1yrpost-treatment
Common Presenting Problems
Abdominal Pain
• seeGastroenterology,G4,GeneralSurgery,GS4,andEmergencyMedicine,ER59
Epidemiology
• 20%ofindividualshaveexperiencedabdominalpainwithinthelast6-12mo • 90%resolvein2-3wk
• only10%arereferredtospecialists,ofthose<10%admittedtohospital
Etiology
• mostcommondiagnosisinfamilymedicineat28%is“nonspecificabdominalpain,”whichhasno identifiable cause and is usually self-limited
• GIdisorders(e.g.PUD,pancreatitis,IBD,appendicitis,gastroenteritis,IBS,diverticulardisease,biliary tract disease)
• urinarytractdisorders(e.g.UTI,renalcalculi)
• gynecologicaldisorders(e.g.PID,ectopicpregnancy,endometriosis)
• cardiovasculardisorders(e.g.CAD,AAA,ischemicbowel)
• other:DKA,porphyria,hypercalcemia,medications(e.g.NSAIDs),alcohol,toxicingestion,foreign
Family Medicine FM13
Some Adverse Medical Consequences of Problem Drinking
• GI: gastritis, dyspepsia, pancreatitis, liver
disease, bleeds, diarrhea, oral/esophageal
cancer
• Cardiac: HTN, alcoholic cardiomyopathy
• Neurologic: Wernicke-Korsakoff syndrome,
peripheral neuropathy
• Hematologic: anemia, coagulopathies
• Other: trauma, insomnia, family violence,
anxiety/depression, social/family dysfunction, sexual dysfunction, fetal damage
Abstinence
Low Risk Drinking
<2 drinks/d
<10 drinks/wk for women <15 drinks/wk for men
At Risk Drinking
Consumption above low-risk level but no alcohol-related physical or social problems
Alcohol Use Disorder
Physical or social problems Continued use despite consequences Inability to fulfill life roles
Legal problems
No evidence of dependence
Figure 6. Continuum of alcohol use
body, psychogenic
If pain precedes nausea/vomiting, cause of abdominal pain is more likely to be surgical