Detailed Assessment

Once it has been established that the patient has problems with alcohol, more detailed assessment is in order. The history should then be focused on the known harmful consequences of alcohol abuse and dependency as related to the patient's history. (For a list of complications, see Woodard, 2009). Major disorders include Wernicke's encephalopathy, withdrawal seizures, cerebellar disease, peripheral neuropathy, cardiomyopathy, cirrhosis, pancreatitis, gastritis, bone marrow suppression, and aseptic necrosis of the hip. A careful history should include an assessment of tolerance and withdrawal symptoms, including shakes, hallucinosis, seizures, and delirium tremens (DTs). The time of the last drink and quantification of daily drinking are prerequisites. A history of stage 2 to 4 withdrawal with or without a history of serious medical complications is in itself justification for acute care hospitalization. Alcohol withdrawal often includes anxiety, nausea, vomiting, diarrhea, tremors, and elevated pulse and blood pressure (BP). A history of blackout or amnesic episodes while drinking must also be elicited. A history of family, social, legal, and occupational complications should be obtained as part of the diagnosis of alcoholism.

A psychiatric evaluation is key in the assessment for alcohol abuse. Screening tools such as the Beck Depression Inventory can help identify underlying depression. Assessment of suicidal ideation must be documented, because alcoholics are at much greater risk for suicide-related deaths. The MiniMental Status Examination (MMSE) can be useful for assessing possible dementia or delirium and pointing to the need for more extensive neuropsychiatry testing (see Chapter 48). Cognitive damage may be a factor in denial, a trait that characterizes many patients with known alcohol dependency. A sexual history should be included, with attention to multiple partners and human immunodeficiency virus (HIV) risk assessment. A history of comorbid polysubstance abuse and intravenous (IV) drug use should also be sought. Cough hemoptysis, night sweats, fever, and weight loss suggest the need to investigate for tuberculosis.

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