PEERLS Tutorial 1:

Substance Abuse

Mr. K a 30 year old unemployed Indian male with a 10 year history of excessive alcohol consumption presented to the psychiatric clinic for a scheduled appointment.

HOPC
He was given the appointment after his admission to the medical wards in HSA on the 21/01/09 for 6 days. At the time he was admitted through the A&E department with severe right upper quadrant pain associated with vomiting and tremors after consuming 3 bottles of “Seven Seas” on his own.
He also complains of having trouble sleeping at night and so “drinks himself to sleep”each night. He mentions that he is easily fatigued as compared to how he was in the past about 3 – 4 years ago. He complains of loss of interest and concentration whilst talking to people as well as when asked to perform any chores around the house. He also complains of feeling helpless as he would like to get married and settle down with a family and a job but has had three failed relationships in the past 10 years. He also feels worthless as he can’t support himself and feels like he has no where and no one to turn to. This has lead to him having several thought of suicide but has never actually attempted it. He mentions having heard voices telling him to commit suicide as well as voices calling him to a certain point. But when he walked towards the voice, he couldn’t locate it. He also complains of having severe headaches when he undergoes stressful situations such as thinking or talking about his past or present situation. He mentions that whenever people were to walk past him and looked at him, he’d feel like they were talking badly about him and this would bother him tremendously. He also expressed his worries about being alone if anything were to happen to his mother as he feels that she is the only person who cares for him genuinely.
He doesn’t complain of any loss of appetite or loss of weight or somatic pain or episodes of extreme joy for no apparent reason.

Social History
Mr. K has been unemployed for the past 4 years. Since then he only holds odd jobs for about 3 days where he makes about RM75 – RM 100 for those 3 days of work at best.
He mentioned that on average he has about 2-3 bottles of “Seven Seas” but on bad days, he has up to 5 – 6 bottles per day. Up until 3 months ago, he always drank with friends but now he drinks at home on his own. He mentioned that he and his friends used to spend an average of RM 100 – RM 200 per day on “Seven Seas”. They would take turns paying for the alcohol each day.

He lives with his parents and two younger siblings. His three older siblings are all married and all the 5 of them are employed. His three older siblings all consume alcohol but not nearly as much as Mr.K does. Mr. K mentions that he has thought of quitting drinking alcohol, but mentions that his family and friends have no faith in him quitting and accuse him of being intoxicated just because of his gait. He also mentions that he receives close to no support from family and friends thus making it very difficult to quit.

Family History
Mr. K does not have any known family history of psychiatric illness. However, his mother suffers from hypertension and his dad, diabetes.

Past Medical History
Four years ago, he suffered from a seizure which resulted in a fall and several external head injuries. Since then he has been having frequent seizures – about once or twice a month. Initially he was hospitalized numerous times for it, as it usually occurred when he was out of the house. But of recent, there hasn’t been any major effects of the seizures. He also has been hospitalized 4 times over the past 5 years (Kulai, Kluang and HSA) for similar presentations as his most recent hospitalization.

Drug/medication History
CAGE questions
Severity of dependance – drinking pattern and if they get tremors and/or pain

Ddx:

1. Major depression with psychosis
2. Alcohol dependence/ Substance abuse with psychosis and other

Tasks:
1. Complications of Alcohol Dependence Christine
2. Evidence based medicine on the relationship between alcohol dependence and depression mano
3. How to manage a patient with alcohol dependence saree
First line
Biological, psychological and social management
4. Summary of other types of substance abuse (effects, complications) and how to manage them – MJ, heroin, amphetamines chris
5. Dangerous drug ordinance maz
What happens when a drug addict presents to the hospital?
What happens when a drunk driver presents to the hospital?
Notification, documentation, who you have to call -
Compare rules & regulations in Australia.
Etc etc etc you get the picture
6. What is the role of the different care providers & the integration of care
Police, social workers hospitals etc etc yazid
7. Diagnosis (history taking & investigations) to rule in/out alcoholic dependence. alvin