History and Physical

Journal Article Summary

Advances in Alcoholism Treatment

G.R. is a 44 y/o M with severe alcohol dependence. He initially presented to ED two nights ago for intoxication at a train station. He was discharged home after a social worker evaluation; however, he did not go home. He states he went and drank again. Two days later, he was admitted to ED again with alcohol intoxication and epigastric pain. He stated he wants help to quit drinking. Patient was admitted to IM for alcohol withdrawal. I wanted to know what options could be offered to alcohol-dependent patients in regard to quitting so I chose the article “Advances in Alcoholism Treatment.”

Alcoholism Treatment

* There is no single treatment that’s effective for everyone with alcohol dependence.

* Instead, clinicians and researchers propose assigning patients to treatment based on specific needs and characteristics. Such as severity of alcohol involvement, cognitive impairment, psychiatric severity, gender, motivational readiness to change, and social support.

Alcoholics Anonymous & the 12-Step Program

* Alcoholics Anonymous is a fellowship of people who come together to solve their drinking problem. It doesn’t cost anything to attend A.A. meetings. There are no age or education requirements to participate. Membership is open to anyone who wants to do something about their drinking problem.

* 12 Steps is based on the premise that turning one’s life and will over to a personally meaningful “higher power.” In the 12 steps program, sobriety or recovery depends on the admission of powerlessness with respect to alcohol or other substances of abuse. The model called for an individualized treatment plan with active family involvement in a 28-day inpatient setting and participation.

* Patients with low psychiatric severity were best suited to 12­step facilitation therapy than those treated with cognitive–behavioral therapy (these patients had more abstinent days).

Behavioral Therapy

* The behavioral treatment integrated aspects of cognitive–behavioral therapy, motivational interviewing, and 12­step facilitation. It also included general behavioral principles like reinforcement and punishment, coping skills training, and brief interventions.

* In cognitive behavioral therapy the concept of self-efficacy (belief in one’s ability to abstain from alcohol) plays a prominent role in relapse prevention. Also, a person’s expectations regarding the effects of alcohol are identified and challenged during CBT interventions.

* In coping skills training and relapse prevention, there is a primary focus on identifying high­ risk situations for drinking and then building a repertoire of coping skills to help patients approach risky situations without using alcohol.

Medications

* Naltrexone helps to reduce the craving for alcohol after someone has stopped drinking.

* Acamprosate is thought to work by reducing symptoms that follow lengthy abstinence, such as anxiety and insomnia.

* Disulfiram discourages drinking by making the patient feel sick after drinking alcohol.

* Other types of drugs are available to help manage symptoms of withdrawal.

Combining Medications and Behavioral Interventions

*  Patients who received naltrexone, behavioral therapy, or both demonstrated the best drinking outcomes after 16 weeks of treatment.

* Acamprosate showed no evidence of efficacy, with or without behavioral therapy.

Choosing the most appropriate treatment for a given patient remains a challenge. The delivery of alcohol treatment, whether that treatment is medication, behavioral therapy, or a combination of both, can be facilitated by the use of communication tools such as the telephone, e­mail, and the Internet. Among the applications being used are Internet and computer program–based screening instruments (e.g., www.AlcoholScreening.org), online social support groups, Internet­ based interventions, telephone contact, e­mail, and text messaging. There is also a technology, called A­CHESS (Addiction Comprehensive Health Enhancement Support System), which is designed to provide coping competence, social support, and autonomous motivation. It’s often provided to patients as they leave residential treatment.

References:

Huebner, R. B., & Kantor, L. W. (2011). Advances in alcoholism treatment. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism, 33(4), 295–299

PDF Attachment

Site Evaluation Presentation Summary

My site evaluator for my first rotation was Professor Fahim Sadat. During my site evaluation, I presented 3 H&Ps that I had written on my patients from my time in Internal Medicine at North Shore University. The 1st H&P I presented was a case of a 43-year-old female who presented with a complaint of difficulty breathing. The patient already had a history of cardiomyopathy with a reduced ejection fraction of 20% and AICD. Her physical exam was notable for 12-14cm JVP, 2+ BLE Pitting Edema. My differentials included acute HF exacerbation, PE, Pulmonary HTN, and Pericardial Effusion. I did not include Cardiac Tamponade because the patient’s vital signs were within normal range. The patient was admitted for acute HF exacerbation and was started on Lasix 40mg IVP BID. The plan also included strict I&Os, daily weight measuring, and to replete Mg and K. For my 1st H&P, we had a long discussion on the differential diagnosis for this case, the pathophysiology of decompensated heart failure, and on the adverse effects of loop diuretics. I got some feedback on including lab values and imaging results. In addition, he recommended that I address all of the patient’s PMHx in the assessment and plan, not just the active complaints. 

On my second site visit, I presented the second H&P which was a case of a 44-year-old male who had a history of severe alcohol dependence and presented with stomach pain x 3 days. On exam, pt was agitated and in mild distress with diaphoresis, had fine hand tremors, and had epigastric tenderness to palpation but was otherwise stable. Differentials included Alcohol Dependence Withdrawal, Pancreatitis, PUD, and Alcohol Induced Gastritis. This time I included labs and imaging, and interestingly enough for this case Lipase was 118. The plan was to admit the patient for alcohol withdrawal, and give lorazepam, thiamine, and folic acid. For the abdominal pain, alcoholic gastritis vs gastric ulcer was considered. Hence, a trial of Carfate was recommended with a CT Abdomen and Pelvis ordered. In addition, the CIWA monitoring protocol was ordered to assess the severity of his withdrawal symptoms. For future site evaluations, my plan is to become more familiar with the different scores that are used in clinical practice. I was vaguely familiar with the CIWA protocol, but there are a lot more scores and criteria that I can learn about. In addition, one of the biggest areas that I can work on is learning the pathophysiology of certain diseases and learning the mechanism of action for drugs. I find reading or watching videos about the pathophysiology and then trying to connect it to the clinical signs or symptoms, helps me understand the disease process better. 

Typhon Posting

Rotation Self Reflection

1. What was a memorable patient or experience that I’ll carry with me?

Starting off, the first rotation in clinical year will always be a memorable one. My first rotation was at North Shore University in Internal Medicine. Initially, I had a hard time adjusting the first 2 weeks with trying to make sense of the hospital structure, hierarchy, and the roles of the different teams. During my time there, the one thing that stood out to me was how patients were constantly being checked in on by the medical team and how they were constantly updated and included in the medical team’s care plan. I was really impressed with the professionalism of the medicine team and how efficiently they worked, especially when they were faced with a high patient volume from the recent nurse strike. The most memorable patient encounter I had, was with an 80-year-old man who was admitted for fungemia and bacteremia. The first time I met him, he was delirious and in a lot of pain. In my eyes, I was unsure if he would get better. To my surprise the second time I came across him, he was doing much better and recovering. However, now he was being worked up for infectious endocarditis but because of his old age he refused surgery, and that’s when the palliative care team became involved. This case was a perfect reminder of respecting the patient’s autonomy in refusing medical care. I will always feel like I did not learn as much, since there will always be something new to learn. Although I was in Internal Medicine, thanks to PA Dawn Coburn I had opportunities to see a Cardiac Catheterization, TAVR, Mitral Clip Surgery, Endoscopy, and Colonoscopy. 

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them

This is my 1st rotation, so there is a lot to learn and improve on. I gained a lot of experience with handoffs. Typically, when I prepare handoffs to providers I update them on any change in the patient, on any pertinent labs/imaging, and on the pending consult recommendations. I’m still learning how to give presentations and focused H&Ps. Procedural-wise, I realized I was quite sheltered in regards to practicing phlebotomy on dummies. The reality is, patients will often have veins that are difficult to access. Most of the time the veins are not superficial and they will roll. In addition, if the patient is elderly or dehydrated it adds another fun layer of challenge with collecting blood. My plan to get better at phlebotomy is to practice more with nurses; the nurses are pros and give great feedback.

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

I always struggle with getting history from altered patients. In my mind, I assumed it would be impossible to get information from patients that have dementia or delirium. However, during my time there I realized that was not true. Patients with dementia can still tell you if they are in pain or point toward the area that’s causing them discomfort. While working with the PA Dawn Coburn, I learned that even if some of the patients can’t speak, you can look at them and tell if they are in distress. That’s why before starting rounds, we would go see the patients just to get “eyes” on them. 

4. What do you want to improve on for the following rotations? What is your action plan to accomplish that?

I want to get better at patient education and giving informed consent to the patient. Informed consent is based on giving the patient all the treatment options and telling them about the risk and benefits. One way, I can work on this is by learning about the different treatment options by reading up on them on UptoDate or asking other providers. It would also help to improve my assessment and plan, review other provider notes, and listen to conversations providers have with patients as they discuss informed consent.