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PCL II CASE-VII: STUDENT LEADER GUIDE

Problem Oriented Case Based Learning 2

Case 7 Michael Phillips: Standardized Patient 2011-2012

Julia Frank, MD

Department of Psychiatry

Seema Kakar, MD

Department of Medicine

Matthew Mintz, MD

Department of Medicine

Gisela Butera, MLIS

Himmelfarb Library

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TABLE OF CONTENTS

I. OVERVIEW OF THE CASE ……………………………………… 2

II. SPECIAL INSTRUNCTIONS FOR STUDENT LEADERS …… 4

III. SESSION 1: MANAGING THE DISCUSSION………………… 5-6

IV. SESSION 2: MANAGING THE DISCUSSION………………… 7

V. APPENDIX I - Summary of Evidence on Alcohol Treatment Options… 8-12 VI. HANDOUT 1: BACKGROUND INFORMATION ON PATIENT………. 13-14 VII. HANDOUT 2: FUTURE COURSE OF PATIENT’S LIFE……………… 15-16 VIII. HANDOUT 3: AUDIT INTERVIEW ……………………………………… 17-18 IX. HANDOUT 4: ORAL CASE PRESENTATION CHECKLIST…………… 19 X. USMLE QUESTIONS……………………………………………………….. 20 XI. LEARNING OBJECTIVES FOR STUDENTS…………………………… 21 XII. Case 7: Michael Phillips PowerPoint Slides…………………………….. 22-27

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OVERVIEW OF THE CASE:

In contrast to other PCL cases, this one presents the patient, Michael Phillips, as a live person (standardized patient) at a crucial juncture during the chronic illness of alcoholism, when he has developed a serious but not life threatening medical complication. At the time of interview, the patient will be able to give a history of the early stages of alcohol use, including the effect of a primary care intervention that delayed progression of the illness, although he is now in relapse. Students will begin the interview, but it is expected that the tutor will step in and make suggestions if the students do not get to the important points. After the initial interview and discussion, the STUDENT LEADER will model with the patient a brief intervention appropriate to this stage of his alcohol use (FRAMES Intervention). In subsequent handouts, students will get a look into the future—the effects of the patient either becoming sober or progressing to end stage alcoholism with withdrawal seizures and cirrhosis.

Learning objectives for this case include the concept of natural history of disease,

differences and similarities in alcohol related problems in men and women, and the possible role of physicians in motivating patients to change destructive behaviors.

Michael Phillips is a 40-year-old man who is seeing a primary care physician

complaining of abdominal pain which turns out to be hepatitis, related to heavy drinking. He is divorced, with joint custody of two children aged 10 and 14. The patient’s drinking contributed to the divorce. He began drinking in high school and was a serious weekend binge drinker in college. After flunking a major course as a result of taking the exam after a night of vomiting brought on by drinking Michael, was advised by a student health physician to cut back or stop drinking altogether. He managed to reduce drinking to occasional “nights out”—rarely binges, but only 2-4 times per year. The patient married someone who also drank, but in moderation. He smoked marijuana fairly regularly in college, but did not use other drugs, and has not used marijuana as an adult. Michael works in the events planning industry.

NOTE: Hospitality industry workers have some occupational risk for alcohol related problems. They are expected to attend events where alcohol is cheap and available, and drinking improves the ability to schmooze with clients. Hospitality industry workers are also in a job where they may have a lot of independence/freedom from direct oversight.

* Opportunity for students to investigate other high risk occupations,

including being in the military, house painting, restaurant work, security guard, etc.

Michael began to drink heavily again when he took a second job to help pay for

his children’s expenses. The second job was on Fridays and Saturdays, 11-7 and Wednesdays 5-midnight as a hotel manager. He justified the resumption/acceleration of drinking as necessary because of problems falling asleep during the daytime after nights of work and difficulty falling asleep at normal hours during the week. However, it

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progressed to the point when he couldn’t fall asleep without drinking, and he also felt the need to drink at work, feeling this helped him cope with the crises that occurred there. NOTE: Alcohol does calm heavy drinkers down, so they often justify use as a coping mechanism. A subtle point is that the drinker is inappropriately substituting emotion-focused coping—relieving anxiety—for problem focused coping when under stress.

Over the past five years, Michael has developed physical, psychological, and social complications related to alcohol use. His spouse left because of the drinking, which disrupted their sex lives, made him irritable at times and emotionally out of touch at others. He now has problems keeping up with the financial obligations related to child support. He has been passed over for promotion at work, due to frequent “sick days”—many, but not all of which, are due to hangovers.

At the time of the interview Michael drinks 5 beers per day and the equivalent of seven mixed drinks when he goes out. He developed anorexia, nausea, moderate Right Upper Quadrant (RUQ) pain, and dark urine and comes to the doctor’s office.

Lab studies show mild hepatitis (Hep B and C are negative). If he is asked, he should deny having had signs of GI bleeding (hematemesis or tarry stools), or more severe abdominal pain suggesting pancreatitis. Michael admits to occasional sex without condoms. He has had and has had a few blackouts, but not DTs or seizures during withdrawal.

SESSION 1: SPECIAL INSTRUCTIONS FOR STUDENT LEADERS:

Go to Blackboard PCL Case 7 and view the training video of Dr. Julia Frank with standardized patient conducting an “intervention” for Michael Phillips alcohol use

Review the “Sample Script for Frames” (Available on Blackboard PCL Case 7)

Be prepared to conduct the “Intervention” interview with the standardize patient during the second half of Session 1.

After the “intervention” with the standardize patient, the class may ask the SP for any comments/feedback on the initial interview or questions and then let them him leave

Distribute Handout 2 “Future Course of Patient’s Life” and have the class review “Pathway One” and “Pathway Two.”

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SESSION 1: MANAGEMENT OF THE FIRST SESSION

TO DO:

Go to Blackboard and open PowerPoint presentation: “PCL2_Case7_Michael Phillips.pptx”

First Half: Begin by asking for a student volunteer to interview the patient (this is a common exercise in their DPS course so they are familiar and relatively comfortable with this). Introduce the standardized patient, Michael Phillips, but do not give any background.

During the course of the interview, the student interviewer may take a “time out” to collect their thoughts, ask the audience for input, and then continue.

When they feel they have an adequate history, have a student write out the problem list and differential diagnosis using the Clinical Notes & Problem List slides. As the students think through the possibilities, they will likely have additional questions they will wish to ask and should do so to the standardized patient.

After the initial interview and discussion, please distribute Handout 1 (additional background, physical exam and lab results) and have the students read through it.

Go to PowerPoint “Two Days Later.” The doctor’s phone call to the patient informs him the lab results show he has inflammation of the liver and he has hepatitis. Doctor recommends to “give the liver a rest” and asks Mr. Phillips to abstain from alcohol. Michael schedules to follow up in one week

Second Half: The follow up visit will be conducted by the Student Leader who will model with the patient a brief intervention appropriate to this stage of his alcohol use. (Preparation for the interview the student Leader should go to Blackboard PCL Case 7 to view the training video and Sample Script for FRAMES). After which, you may ask the SP for any comments/feedback on the initial interview or questions and then let him leave.

Distribute Handout 2 students will get a look into the future—the effects of the patient either becoming sober or progressing to end stage alcoholism with withdrawal seizures and cirrhosis.

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Potential Discussion Points

"What might be causing Michael's abdominal pain?"

"What could happen to Michael if he continues drinking in this fashion?"

"How do individuals "become" alcoholic?"

"How is alcohol absorbed and metabolized?"

"How could alcohol cause Michael's problems?"

"How do you diagnose alcoholism?"

"What would you do for Michael now?"

"How has alcohol use affected Michael? His family? His work?"

"How would you try to get Michael to stop drinking?"

"Are these interventions effective? If so, how?"

"What makes people change their behavior?

Concluding the Session

Go to PowerPoint Slide on Learning Objectives

Assign learning objectives for student presentations

Have a student volunteer to present Michael Phillips as an oral case presentation for the next session, as if just seen in the office (distribute Handout #4, Oral Case Presentation Checklist as an aid. (Oral Presentation Check List and Oral Presentation PowerPoint available on Blackboard)

Distribute the AUDIT screening handout for students to fill in themselves. Option to discuss AUDIT quesionnaries (NOTE: Does not need to be handed in but option to discuss it as a group. Exercise allows the students to become familiar with the questions and “screen themselves”.)

Required Reading:

Mailliard M.E., Sorrell M.F. (2012). Chapter 307. Alcoholic Liver Disease. In D.L. Longo, A.S.

Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison's Principles of

Internal Medicine, 18e. Retrieved January 26, 2012 from

http://www.accessmedicine.com/content.aspx?aID=9134918.

Supplemental Readings:

Fagbemi, K. (2011). QWhat is the best questionnaire to screen for alcohol use disorder in an

office practice? Cleveland Clinic Journal of Medicine, 78(10), 649-651.

Fiellin, D. A., Reid, M. C., & O'Connor, P. G. (2000). Screening for alcohol problems in primary

care: A systematic review. Archives of Internal Medicine, 160(13), 1977-1989.

Webb, G., Shakeshaft, A., Sanson-Fisher, R., & Havard, A. (2009). A systematic review of work-

place interventions for alcohol-related problems. Addiction, 104(3), 365-377.

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SESSION 2: MANAGING THE DISCUSSION

TO DO:

Start with the Oral Case Presentation.

Begin student presentations of learning objectives

Ask the students to use the checklist to give feedback before you give additional feedback. This is an important skill we want the students to practice in a supportive environment

Review objectives and presentations identified at the last session.

Complete the USMLE questions on slides.

KEY POINTS

• Alcohol misuse is one of the leading causes of morbidity and death in the United States.

• Alcohol use disorders are heterogeneous disorders that require assessment and an

individualized clinical approach.

• Presentation of an alcohol use disorder is often complicated by the presence of co-morbid

psychiatric symptoms and disorders that require assessment and monitoring, as well as an

integrated treatment approach.

• It is possible to screen effectively and efficiently for the presence of an alcohol use disorder

using brief, validated measures.

• Treatment outcomes for alcohol use disorders are similar to, or better than, outcomes for

other chronic illnesses.

Concluding the Case

Please elicit feedback

Assign a student leader for the next case.

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APPENDIX I - Summary of Evidence on Alcohol Treatment Options

(from FirstConsult)

Naltrexone is more effective at reducing drinking frequency and amount, than in enhancing abstinence. Its proven efficacy is as an adjunct to psychosocial therapy.

A systematic review found that naltrexone reduced short-term relapse rates, when combined with psychosocial treatments. Short-term outcomes in favor of naltrexone included fewer patients relapsing to alcohol dependence, fewer patients returning to drinking, reduced cravings for alcohol, and fewer drinking days. One relapse was prevented for every five patients treated with naltrexone Level A

Another systematic review concluded that both acamprosate and naltrexone were effective as adjuvant therapies for alcohol dependence in adults. Naltrexone appearing more useful in programmes geared to controlled consumption Level A

A large randomized controlled trial evaluated the efficacy of medication, behavioral therapies, and their combinations for treatment of alcohol dependence. It also assessed the placebo effect on overall outcome. It found that patients receiving medical management with naltrexone, a combined behavioural intervention (CBI), or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy, with or without CBI. No combination produced better efficacy than naltrexone or CBI alone in the presence of medical management. Placebo pills and meeting with a health care professional had a positive effect above that of CBI during treatment ]Level A

Other studies, however, report mixed results: a further systematic review found no difference between naltrexone and placebo in medium-term (six to 12 months) outcomes Level A

A meta-analysis evaluated the efficacy of five categories of drugs used to treat alcohol dependence: disulfiram, opioid antagonists (including naltrexone), acamprosate, serotonergic agents, and lithium. It found that naltrexone reduced the risk of relapse to heavy drinking and the frequency of drinking, compared with placebo. It did not, however, substantially enhance abstinence (that is, the avoidance of any alcohol consumption) Level A

A randomized controlled trial examined the interactive effect between naltrexone and the type of psychological therapy given. A lower percentage of heavy-drinking days was shown in the naltrexone group compared with placebo, as was a lower craving score. The mean time period before the first day of heavy drinking was longer for the group treated with cognitive behavioral therapy (CBT), especially when combined with naltrexone. The study supported the positive effect of naltrexone in the outpatient setting, and suggested that a beneficial interactive effect with CBT can be expected Level B

A cohort comparison studied treatment outcomes with either naltrexone or acamprosate, used singly or in combination, in an outpatient CBT programme for

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alcohol dependence. It found that naltrexone with CBT was as effective as combined medication (naltrexone plus acamprosate) with CBT. The trend, however, was in favour of combination medication Level B

Acamprosate reduces frequency and amount of alcohol consumption, with some enhancement of abstinence. Its proven efficacy is as an adjunct to psychosocial therapy.

A systematic review showed that acamprosate reduced short and long-term relapse rates in alcohol-dependent patients, when combined with psychosocial therapies Level A

Another systematic review concluded that both acamprosate and naltrexone were effective as adjuvant therapies for alcohol dependence in adults. Acamprosate appearing to be especially useful in a therapeutic approach targeted at achieving abstinence Level A

A large randomized controlled trial evaluated the efficacy of medication, behavioral therapies, and their combinations for treatment of alcohol dependence. It also assessed the placebo effect on overall outcome. It found that patients receiving medical management with naltrexone, a combined behavioral intervention (CBI), or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy, with or without CBI. No combination produced better efficacy than naltrexone or CBI alone in the presence of medical management. Placebo pills and meeting with a health care professional had a positive effect above that of CBI during treatment Level A

A meta-analysis evaluated the efficacy of five categories of drugs used to treat alcohol dependence: disulfiram, opioid antagonists (including naltrexone), acamprosate, serotonergic agents, and lithium. It found that acamprosate reduced drinking frequency, although its effects on enhancing abstinence or reducing time to first drink were less clear Level A

A cohort comparison studied treatment outcomes with either naltrexone or acamprosate, used singly or in combination, in an outpatient CBT programme for alcohol dependence. It found that naltrexone with CBT was as effective as combined medication (naltrexone plus acamprosate) with CBT. The trend, however, was in favour of combination medication Level B

Disulfiram may reduce drinking frequency, but evidence is lacking to support its role in enhancing abstinence.

A meta-analysis evaluated the efficacy of five categories of drugs used to treat alcohol dependence: disulfiram, opioid antagonists (including naltrexone), acamprosate, serotonergic agents, and lithium. Controlled studies of disulfiram revealed a mixed outcome pattern: some evidence that drinking frequency is reduced, but minimal evidence to support improved continuous abstinence rates Level A

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Benzodiazepines are the drug of choice for acute alcohol withdrawal treatment.

A meta-analysis showed that benzodiazepines were superior to placebo in the treatment of patients suffering acute alcohol withdrawal symptoms. Data on comparisons with other drugs, including beta-blockers, carbamazepine and clonidine, could not be pooled. None of these alternative types of drugs was found to be clearly more beneficial than the benzodiazepines. It summized that benzodiazepines should remain the drugs of choice for the treatment of acute alcohol withdrawal Level A

Thiamine is a long established treatment for the prevention of Korsakoff's psychosis, secondary to alcohol excess.

For over 50 years, thiamine has been established as the treatment of choice in preventing Korsakoff's psychosis secondary to alcohol excess. The evidence for its benefit is based on case reports and clinical experience

A recent systematic review was only able to find and analyze one randomized controlled trial on the use of thiamine in people at risk of Korsakoff's psychosis secondary to alcohol excess. Five different doses of thiamine, given intramuscularly over 2 days, were compared. The pattern of results did not present a simple dose-response relationship, and due to methodological shortcomings and poor presentation, no further conclusions could be drawn from the results Level A

Other therapies, like motivational interviewing (MI), behavioral therapy, cognitive behavioral therapy (CBT), psychodynamic therapy, self-help, and group therapy also have a role in the treatment of patients with alcohol dependence.

Brief motivational interviewing (MI) has been shown to be effective in reducing alcohol consumption and, in a scientific setting, outperforms traditional advice giving in the treatment of a broad range of behavioral problems and diseases, Level A

Adaptations of MI have shown clinical impact, resulting in a 56% reduction in client drinking ]Level A

Furthermore, substantial evidence supports the use of MI as an effective intervention in substance abuse, when used by clinicians who are not specialists in this area Level A

A large randomized controlled trial evaluated the efficacy of medication, behavioral therapies, and their combinations for treatment of alcohol dependence. It also assessed the placebo effect on overall outcome. It found that patients receiving medical management with naltrexone, a combined behavioral intervention (CBI), or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy, with or without CBI. No combination produced better efficacy than naltrexone or CBI alone in the presence of medical management. Placebo pills and meeting with a health care professional had a positive effect above that of CBI during treatment Level A

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An effectiveness study tested whether conflict reduction can be expected not only in psychodynamic, but also in cognitive-behavioral therapy (CBT). Results showed significant conflict decrease in both treatment groups, with a tendency towards faster reduction under CBT Level B

The role of self-help groups in the outpatient setting was analyzed, where three conjoint treatments were tested: alcohol behavioral couples therapy (ABCT); ABCT with relapse prevention techniques (RP/ABCT); or ABCT with interventions encouraging Alcoholics Anonymous (AA) involvement (AA/ABCT). The latter group of participants attended AA meetings more often than ABCT or RP/ABCT participants, and their drinking outcomes were more strongly related to concurrent AA attendance. For the entire sample, AA attendance was positively related to abstinence during follow-up in both concurrent and time-lagged analyses Level B

Another trial assigned problem drinkers to one of four groups, receiving either: general advice and information booklet; a behaviorally-based self-help manual; in addition to the manual, an opportunity to make progress reports to a telephone answering service; and in addition to the manual, an opportunity to make telephoned progress reports to an interviewer. Results showed a higher proportion of drinking above recommended limits at six months follow-up in the control group (78%) than in the groups receiving the manual (53%). There were no significant differences due to presence or type of telephone contact, and poor use was made of the opportunity for telephone contact. It concluded that the results justified the widespread promotion of self-help materials as a means of assisting the natural recovery process among problem drinkers Level B

The effectiveness of individual versus group CBT was evaluated in the context of alcohol and/or drug dependent patients. At follow-up evaluation both groups of patients presented similar levels of drug consumption, dependence and associated problems. Although group-treated patients reported slightly higher levels of alcohol consumption (both at baseline and follow-up), differences between the formats disappear if baseline levels are included as covariates. The number of sessions attended and high GGT (liver enzyme) levels at admission were positively correlated with success for the alcohol dependents. The two modalities presented similar outcomes, but as the 'group' format could present a better cost-benefit ratio it may be used in preference to 'individual' CBT Level B

Appropriate screening enhances the ability to detect and treat alcohol problems.

A critical review of studies of the CAGE questionnaire found that it has good test-retest reliability, correlates well with other screening tests, and is a valid tool to screen for alcohol dependence and abuse. It is most useful in medical and surgical inpatients, psychiatric patients, and general medical outpatients, but performs less well in white women and in primary care settings Level B

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Clinical pearls

Patients may insist that their emotional problems need to be resolved before they attempt abstinence. They should be firmly told that their alcohol problem must be resolved first before emotional problems can be addressed, and that ongoing alcohol abuse is actually the cause of many emotional problems in alcoholics

Patient denial can be confronted by the challenge to abstain for 1 month. A successful trial period may help the patient feel so much better that continued abstinence becomes easier. An unsuccessful trial period proves that alcohol use is out of control, which then emboldens the therapist to confront the patient's denial more vigorously

Alternately, the patient can be challenged to drink moderately for 1 month, again with the objective of disproving patient insistence of the ability to control their drinking consumption

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HANDOUT 1: BACKGROUND INFORMATION - MICHAEL PHILLIPS

(Distribute after Interview)

Michael’s father was an alcoholic who left his mother when Michael was twelve and his father was 40. He began drinking in high school—once he got his driver’s license; his mother allowed him a lot of independence. He did well in school and attended the University of Delaware, where he majored in business and hotel management. He joined a fraternity, and during the second semester of his freshman year he began to drink quite heavily at fraternity/sorority parties. He was on the track team, so he would limit his alcohol use during the season. In his sophomore year, he began to get part-time jobs as a cater-waiter. Until he turned 21, he did not drink at work.

When he was 20, he was treated at student health for gastritis, which the physician attributed to a severe binge drinking episode. The physician urged him to look more carefully at his drinking behavior. The physician also stressed that alcohol was contributing to his academic problems, and that because of his father’s alcoholism, he was at increased risk to develop the same problem. Michael took this advice to heart, quit the fraternity and finished college. Following the physician’s advice, he limited his intake, though he did not become abstinent.

Michael worked his way up in the hotel industry, beginning as a coffee shop manager and moving into events planning. He enjoyed the partying aspect of the job, and drank most evenings while engaging clients and running events. He met his wife, a lobbyist who frequently entertained at his hotel. During the first years of their marriage, both enjoyed going out with friends, which involved sharing bottles of wine over dinner. They drank with most meals at home. When they decided to start a family, his wife stopped drinking entirely and never picked it up again.

He continued to drink as part of his job. When his second child was born, he felt he needed to take a second job and began working 2 nights and one evening a week. This disrupted his sleep cycle and he would drink on weekdays at home to try to sleep in the daytime. He and his wife began to argue about many things. She disliked his sexual advances when he had been drinking. She felt he let her down by being unavailable during the weekends, when she wanted a break from the childcare/housekeeping tasks that she did during the week.

Michael made a few attempts to cut down on his drinking, but felt it was justified, given the stress of his job and schedule. He wasn’t drinking every day, and he never drove after drinking. Then one day, when his wife came back from a four day trip, she found he had sent their seven year old daughter to school with a severe headache and vomiting, which resulted in the child having to be admitted to the hospital for 24 hours for dehydration. His wife asked for a separation, and demanded joint custody of the children. He began to drink at home when the children were with her, and he started missing work because of hangovers. Two years ago, the couple divorced.

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PHYSICAL EXAM

Physical Examination: Temp: 99.9 BP:138/92 Resp:16 Pulse: 90 Height: 5'11" Weight: 222 lbs. Head/Ears/Eyes/Nose/Throat: no scleral icterus Chest: Clear to ausultation and percussion, no rales/rhonchi Cardiac: regular rate and rhythm, no murmur/rubs/gallops Abdomen: soft, moderate right upper quadrant tenderness, no guarding or rebound

tenderness, liver palpable 4 cm below the costal margin, liver span 14 cm, no palpable spleen.

Extremities: no edema Skin: no obvious jaundice, no rashes Neurologic: normal LABS CBC (Complete Blood Count):

Hgb: 12.8 gm % (14-18) Hct: 39 % (42-52) WBC: 12.0/mm3 X 1000 (4.8-

10) Neutrophils: 75% (40-65) Lymphocytes: 18% (21-44) Monocytes: 5% (0-7) Eosinophils: 2% (0-5)

Platelets: 156,000 (130-400,000) CMP (Comlete Metabolic Panel) Sodium (135-145) 138 Potassium (3.5-5.0) 3.5 Chloride (95-105) 100 Bicarb. (22-30) 31 BUN (10-20) 25 Creatinine (.8-1.5) 1.3 Calcium (8.5-10.5) 9.9 Phos. (2.5-4.5) 2.7 Alk Phos (40-125) 155 ALT (10-45) 96 AST (10-50) 360 Bilirubin (.2-1.3) 1.7 Hepatitis B and C - negative

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Handout: 2 Future Course of Patient’s Life

Pathway One:

During the follow up visit for hepatitis, Michael’s physician asked him to fill out an AUDIT questionnaire in the waiting room. The physician reviewed the answers with him during the visit, Michael’s score of 17 suggested the need for brief counseling with scheduled follow up visits. Following the FRAMES format, the physician helped Michael see that drinking was contributing to several important problems in Michael’s life—in health, work, and family life. Though he was not completely convinced that drinking itself was the problem, not the solution, he initially thought he could cut down on his own. During a follow up visit he admitted that, although he was drinking less often, he was still drinking 5-7 units in an evening and felt this was out of control. The physician offered adjunctive naltrexone but also stressed the need for Michael to change his routines, make connections with people who did not drink or drink heavily. For three months, the physician saw Michael monthly to renew the naltrexone and assess progress. After then, he came in every three months for medication renewals.

Michael managed to avoid severe bingeing, but found that his job was still a problem. He gave up the shift work and took a few courses to become a tax preparer as a second job, which helped. While dating someone who drank, Michael started bingeing again, but when his physician noted this at a regular annual checkup, he acknowledged the problem. He attended a few AA meetings, but at a scheduled follow up told the doctor he quit because he felt the people in the program were not sincere. His doctor suggested he go to different meetings until he found one that seemed right (reminding Michael that AA encourages people starting out to attend ninety meetings in ninety days). Michael eventually found a more congenial meeting and went regularly for a couple of months. He ended the relationship with the drinker, and then went to Al-Anon meetings, where he discussed how drinking had damaged both his parents’ marriage and his own.

Five years after the episode of hepatitis, Michael was working a day shift job. He met and was dating the divorced parent of a child on his child’s soccer team. He had decided to quit drinking entirely, and was able to do so. One relapse—a binge on his fiftieth birthday—was enough to convince him that he simply could not drink. Around this time, his younger child was drinking in college, and Michael asked the physician for advice on how to advise this child.

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Pathway two:

At the follow up visit for hepatitis Michael’s physician noted that alcohol was the most likely cause. He offered Michael naltrexone to help reduce the severity of binges, but Michael thought he didn’t need that, since he didn’t drink every day and could control it when necessary to take care of the children. Over the next few years, Michael came in sporadically for appointments for recurrent sinus infections, GERD and then hypertension.

At age 45, Michael had remarried. His wife was someone he met while out drinking after work. When the children were old enough to say so, they demanded to spend the bulk of their time with his ex-wife. Michael began drinking much more heavily and consistently. At a medical visit when he was fifty, the doctor suggested he go to AA. He attended a few meetings, but quit, feeling the people there weren’t sincere.

At age 54, Michael was brought to the emergency room by ambulance, after being found down on the sidewalk outside of a bar. Michael was divorced from his second wife, working only sporadically as a night security guard.

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HANDOUT 3: AUDIT INTERVIEW (ALCOHOL USE DISORDERS IDENTIFICATION TEST)

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HANDOUT 4: Student Oral Case Presentation Checklist

Opening Line

1. name, age and gender

2.includes pertinent active medical problems or medical background (if applicable—

otherwise state “no other pertinent active problems”)

3. reason for presentation/chief complaint

4. duration of symptoms, i.e ,“three day history of”

Transition

5. Transitions to HPI by indicating last time patient was at baseline health—e.g., “the

patient was in his usual state of health until…”

HPI

6. Uses chronological order

7. Uses relevant seven dimensions--character, intensity 1-10, radiation, timing, aggravating

factors, alleviating factors, associated symptoms [individualize by case]

8. Includes course—getting better, worse, staying the same

9. Presents negative symptoms related to chief complaint

10. Includes any relevant past medical history, surgical history, family history, social

history, as part of HPI

Rest of History

11. Medications (states “no prescription, over-the-counter or complimentary medications”

if negative)

12. Past medical history

13. Social history includes occupation, home situation and tobacco, alcohol, drugs

14. Allergies to medications

Physical Exam and other objective findings

15. Vital signs

16. general description

17. Presents all abnormal findings

18. Presents important normal findings

19. Present physical exam in head-to-toe order

20. Includes labs and study results if applicable, after physical but before assessment and

plan

Assessment and Plan

21. Begins with a summary statement

22. Presents at least 3 item differential diagnosis, [present in what student thinks is the order

of likelihood]

23. Presents rationale for each based on information presented above.

24. Recommends a plan Style

25. Good engagement with listener (good eye contact and energetic voice)

26. Good pace (not too fast or too slow)

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USMLE Questions:

QUESTION 1: A 50-year-old male alcoholic presents with cirrhotic liver disease and chronic

pancreatitis. He has been nauseated for the past several days, and not eating. Blood glucagon

levels are elevated with which of the following results?

A. Stimulation of glycogenolysis in muscle B. Inhibition of insulin secretion C. Stimulation of gluconeogenesis in the liver D. Inhibition of adenylate cyclase E. Inhibition of phospholipase C

ANSWER: C

EXPLANATION: The primary action of glucagon is to increase blood glucose concentration,

which it accomplishes by promoting gluconeogenesis and glycogenolysis in the liver but not

in muscle. These effects are mediated by cyclic AMP, which is produced by hepatic

adenylate cyclase following interaction of glucagon with its plasma membrane receptor.

Interaction of glucagon with different hepatic plasma membrane receptors activates

phospholipase C, which results in a rise in concentration of intra-cellular Ca2+, which further

stimulates glycogenolysis. Although glucagon opposes the action of insulin, it does not

directly affect insulin secretion.

QUESTION 2: A 42-year-old woman presents with an acute onset of fever, jaundice, tender

liver enlargement, and ascites. Liver biopsy reveals histological features of scattered foci

hepatocytes undergoing swelling and necrosis, with neutrophilic infiltration around the affected

cells, and sinusoidal and perivenular fibrosis. This is most suggestive of which of the following?

A. Acetaminophen overdose B. Acute fatty liver of pregnancy C. Alcoholic hepatitis D. Budd-Chiari syndrome

E. Pyogenic liver abscess ANSWER:C

EXPLANATION: Alcoholic hepatitis (also called acute sclerosing hyaline necrosis of the

liver) usually occurs acutely following an alcoholic binge superimposed on steatosis (fatty

liver) or cirrhosis. Variable degrees of liver cell necrosis are present with corresponding

clusters of neutrophils and frequent accompaniment of pericellular and perivenular fibrosis.

Intracellular Mallory bodies are common. Alcoholic hepatitis may range from asymptomatic

to fulminant hepatic failure. Symptoms, which may persist for weeks or months, include

upper abdominal pain, anorexia, fever, tender hepatomegaly, and jaundice. Sever disease

may cause encephalopathy and death.

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LEARNING OBJECTIVES FOR STUDENTS PCL 2 CASE VII

Clinical Problem Solving

List the differential diagnosis of abdominal pain in the setting of alcohol use

Basic and Clinical Sciences

Review alcohol metabolism

Review pathophysiology of alcohol related liver disease Psychosocial, Behavioral, and Developmental Issues

Recognize the role of standardized screening tools such as AUDIT in

evaluating alcohol usage

Be familiar with validated brief intervention tools such as FRAMES

Recognize the impact of alcoholism to all the components in a patient’s life.

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Case 7: Michael Phillips PowerPoint Slides

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