Case history
Case history #1
A 35-year-old man presents for a primary care appointment. He has a history of hyperlipidaemia, prediabetes, and hypertension. His examination is notable for a blood pressure of 165/90 mmHg, which is higher than his previous readings. This prompts further questioning about his alcohol intake. He reports that he drinks 2 glasses of wine each evening, which upon further questioning equates to 4 standard drinks nightly. He denies morning withdrawal symptoms or interference with psychosocial functioning and does not meet criteria for alcohol-use disorder but is diagnosed with at-risk drinking. He is given a brief intervention and upon further discussion expresses a desire to cut back to 1 standard drink per day with the goal of improving his blood pressure. On follow-up 6 weeks later, he was successfully able to reduce his alcohol use, and his blood pressure is 135/80 mmHg.
Case history #2
A 42-year-old woman presents to her primary care doctor to discuss her elevated liver enzymes. She reports drinking several mixed drinks most nights of the week, and 4-5 drinks per day on the weekend. On examination, her liver is within normal size and non-tender. She has no stigmata of cirrhosis. Liver function tests reveal an elevated aspartate aminotransferase and alanine aminotransferase with normal bilirubin and alkaline phosphatase. Liver ultrasound shows fatty changes only. She reports that she started drinking in university at the age of 18. Approximately 5 years ago, she was hospitalised for alcohol withdrawal, and participated in a peer support programme. She stopped drinking for 3 months, but returned to drinking 1-2 drinks a couple times per week after that. However, her drinking escalated after her divorce last year. In the last 6 months she reports that she needs to drink daily otherwise she feels intense cravings, tremors, and anxiety. She is interested in drinking less, but is not sure that she wants to stop drinking completely. She would like to discuss medication options and support groups.
Other presentations
Regular alcohol use is associated with a variety of medical and psychosocial conditions. In the primary care setting, unhealthy alcohol use may be commonly seen in patients with depression, anxiety, high blood pressure, insomnia, weight gain, cognitive disturbances, gastrointestinal distress, and cardiac arrhythmias. It is important to emphasise that many of these conditions may worsen with alcohol use, even at low levels, and that patients do not require a diagnosis of alcohol-use disorder to benefit from reduced alcohol intake. Elevated transaminases are commonly due to alcohol use, and patients with elevated transaminases should be encouraged to reduce or stop drinking for 1-2 months to see if numbers improve.[5] In the acute setting, injuries, altercations, and car accidents should prompt further questioning about alcohol intake in an empathic and non-stigmatising manner.
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