Chapter 32 Unintentional Weight Loss Case Information:

• Mr. A. is a 62-year-old man who complains of recent weight loss. He reports that he has lost 15 pounds over the last 6–9 months, and that his clothes no longer fit. He denies diarrhea but admits to abdominal bloating and having several large stools a day that are difficult to flush. He reports that his appetite is not what it used to be but attributes that to his recent separation from his wife. He confides that they have not gotten along for years. She seemed to blame everything on his drinking, but he assures you that alcohol was definitely not a problem. Further, he reports that he is glad she is out of his life.
• On further questioning, Mr. A reports that he drinks 2 or so alcoholic beverages a night. He proudly states that he has never missed work due to a hangover and never drinks before noon. When you ask him how much alcohol he uses in each drink and whether anyone else has commented on his drinking, he gets defensive and reminds you he is here because he is losing weight.
• Mr. A reports that he probably drinks that much at least once a month when he is “partying.”
• Mr. A scores 15 (out of a possible 40). He acknowledges that he tried to cut down while he was married but since his separation, he no longer feels that restraint. He acknowledges that occasionally he hears funny stories about himself from these parties that he cannot recollect (amnesia). Mr. A also reluctantly reports that he received 2 tickets for driving while intoxicated within the past year. He feels mildly guilty about this but assures you he knows better than to make that mistake again. He reiterates that he has never missed work due to his drinking but did miss several family events because he was “partying.”
• You have a frank discussion of the issues with Mr. A. You acknowledge that his marital difficulties are complex but that many features of his alcohol use suggest an alcohol use disorder. The missed family gatherings, alcoholic blackouts, tolerance, tickets for driving while intoxicated, and abnormal blood test results all suggest this is a serious medical problem. Mr. A confides that he is frightened to go “cold turkey.” He feels shaky and agitated whenever he stops drinking. You suggest admission to a detoxification unit. Mr. A listens carefully and agrees to be admitted.

SOAP Note:

• S: 62 y/o male c/o recent weight loss of 15 pounds over the last 6-9 months. Patient recently separated from his wife due to alcohol issues. He reports drinking 2 alcoholic beverages a night, at least once a month when “partying”. Patient has tried cutting down his alcohol intake but has stopped since the separation with his wife. Since then, he received 2 tickets for driving while intoxicated within the past year. Patient has never missed work due to drinking but has missed family events. He denies having diarrhea but admits to abdominal bloating, loss of appetite, and having large, difficult to flush stool daily.
• O: Vitals not stated.
  • Audit score questionnaire: 15/40
  • CBC: Evidence of macrocytosis
  • Liver panel: Mild elevation of AST and ATL
• A: R/O alcohol use disorder – 62 y/o male, current alcohol use, with amnesia, macrocytosis, elevated AST/ATL
• P: Admission to a detoxification unit for 30-45 days depending on progress. F/u in six weeks, then yearly to assess sobriety.

Summary of Alcohol Use Disorder (AUD)

• Alcohol intake varies from a scale of low to high risk: risk use, problem drinking, abuse, and alcohol dependence. This can lead to psychosocial complications such as losing your job, marital difficulties, and losing your driver’s license. Medical complications include injury, pancreatitis, gastritis, cardiomyopathy, hypertension, malnutrition, unintentional weight loss, and death.
• In the United States alone, alcohol is responsible for 79,000 deaths each year and affects 9% of the U.S. population. Women deny alcohol-related problems, eating disorders, depressing, and panic disorders more than men.
• Risky use criteria involves a prevalence of 4-29%:
  • Men less than 65: ≥ 14 drinks per week or ≥ 4 drinks per occasion
  • Women and men above 65: ≥ 7 drinks per week or ≥ 3 drinks per occasion
• The USPSTF recommends annual screening for alcohol misuse in all adults
  • 3 recommended screening tools: 10-question Audit tool, 3-question Audit-C tool, or “how many times in the past year have you had 5 (or 4 for women) or more drinks per day?”
  • Audit score of ≥ 4 in men (≥ in women) has sensitivity of 84-85%, specificity of 77-84%
• The DSM-V defines AUD as “a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 2 of the following” over a span of 1 year:
  • Consumption of more alcohol or for a longer period of time than intended
  • Persistent desire to cut down alcohol intake
  • Spending a lot of time obtaining, using, recovering from alcohol
  • Strong desire for alcohol
  • Recurrent instances to fulfill obligations
  • Continued use despite medical/social/psychological problems caused by alcohol
  • Decrease of social, occupational, recreational activities
  • Tolerance
  • Withdrawal
• Laboratory abnormalities
  • Elevated gamma glutamyl transpeptidase (GGT), macrocytosis (should not R/O diagnosis but important to keep in mind)
  • Sensitivity increases if patients are alcohol dependent
• Treatments
  • Brief 6-15 minute counseling has been effective in reducing weekly consumption, injury, heavy drinking, and death
  • Specialty referral
  • Feedback on screening/lab tests
  • Comparison to drinking norms
  • Discussing adverse effects of alcohol
  • Recommend drinking limits
  • Patient education
  • F/u sessions or phone contact
  • Detoxification unit
  • Alcoholics Anonymous (AA): 12 step program to increase abstinence
  • Motivational enhancement therapy
  • Naltrexone, acamprosate, disulfiram (pharmacotherapy combined with behavioral support is best)
  • Treatment if depression, if applicable

This is a YouTube video on alcohol use disorder as presented by another student, Erin Henninger.

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