Reason for the Visit
Mr. X, a 39-year-old male, complains of increased alcohol intake (usually more than six bottles of beer) during the last two months, which does not bring him satisfaction but causes fatigue and poor sleep. His wife is concerned that the man gets irritable, forgets some important events, and loses interest in daily activities with children.
History of Present Illness
One month ago, the wife noticed his husband buying too many beers and drinking at home or visiting a local bar. Several weeks ago, Mr. X admitted to Mrs. X he was not happy and felt tired during the day. During the last several weeks, the couple had quarrels more than ten times, which negatively affected their children and financial issues.
Review of Systems
The patient is negative for headache, chest pain, abdominal pain, diarrhea, nausea, and vomiting. However, Mr. X is positive for dizziness, swelling on his face, and frequent urination.
Past Medical/Surgical History
- 10-year-old hypertension, no other vascular diseases
- Ulcerative colitis five years ago, but it is calm at the moment.
- An appendectomy ten years ago, with no complications.
Medications and Allergies
- Lisinopril 10 mg once a day
- Amlodipine 5 mg once a day
- No allergies
Social/Family History
Both parents are alive and hypertonic; the father has diabetes, and the mother is healthy. Mr. X is married (15 years); his wife is supportive and wants her husband to quit his drinking habit. The couple has two children who go to school; they live together. The patient lost his well-paid job one year ago, and now, he is an office manager with a middle income. He denies drug use but smokes irregularly (one pack per month occasionally).
Physical Exam
- Vital signs: T: 98; P: 90; BP: 160/90; RR: 20; BMI: 21.
- HEENT: WNL, except for slightly puffy eyes.
- Lungs: insignificant murmurs in the lungs.
- Abdomen, extremities, neurology: WNL.
Labs and Imaging
- WBC: 4,000 with 10% bands.
- Urine test: ethyl glucuronide of 250 ng/mL.
- No imaging is required at the moment.
Assessment and Plan
Differential diagnoses of the patient are:
- major depression (the patient has no interest in daily activities and feels fatigued regularly)
- generalized anxiety disorder (the patient is easily fatigued and becomes irritable)
- primary insomnia (the patient has difficulties falling asleep)
The most highly suspected diagnosis for Mr. X is alcohol use disorder. The patient has a disrupted mood (irritability), cognitive concerns (no interest in everyday activities), and physical issues (fatigue) (McHugh & Weiss, 2019). At this moment, Mr. X is interested in getting treatment and managing his alcohol habits, and he is supported by his wife.
The patient’s treatment plan for alcohol use disorder should contain several pharmacological and non-pharmacological interventions. Following the American Psychiatric Association guidelines, topiramate is recommended to improve drinking behavior and maintain abstinence (Burnette et al., 2022). Oral administration of Naltrexone (50 mg daily) for 12 weeks is also effective, according to the U.S. Food and Drug Administration (1994, as cited in Burnette et al., 2022). Alcoholics Anonymous (AA) meetings should be offered to the patient to help him achieve abstinence from alcohol as a long-term goal and improve relationships with family members as a short-term goal (Kelly et al., 2020). Couple therapy is also a beneficial non-pharmacological treatment to support the patient in changing his lifestyle and quitting drinking in a short period.
Patient education plays an important role in improving the patient’s well-being. Mr. X has to understand that alcohol can make people happy and reduce stress, but all these are short-term outcomes that provoke dependence. With time, increased family problems, job loss, and accidents can emerge and affect the quality of life (McHugh & Weiss, 2019). Heavily drinking is also associated with health problems, including liver damage, heart disease, and brain damage. The patient’s father is diabetic, and Mr. X is at risk of developing excessive blood sugar levels (increased with alcohol intake). Thus, alcohol abstinence is the best solution for the patient in this case.
References
Burnette, E. M., Nieto, S. J., Grodin, E. N., Meredith, L. R., Hurley, B., Miotto, K., Gillis, A. J., & Ray, L. A. (2022). Novel agents for the pharmacological treatment of alcohol use disorder. Drugs, 82(3), 251-274. Web.
Kelly, J. F., Abry, A., Ferri, M., & Humphreys, K. (2020). Alcoholics anonymous and 12-step facilitation treatments for alcohol use disorder: A distillation of a 2020 Cochrane review for clinicians and policy makers. Alcohol and Alcoholism, 55(6), 641-651. Web.
McHugh, R. K., & Weiss, R. D. (2019). Alcohol use disorder and depressive disorders. Alcohol Research: Current Reviews, 40(1). Web.