Case one:

Liz, aged 46 years, works as an administrative assistant for a medium sized retailing company. Her husband Peter, is a sales manager who is often away on business trips. They have two adult children, Shane aged 22 and Stephanie aged 24 who have both left home.

Liz is an exsmoker and is currently not taking any medications. She has no significant family history.

She presents describing episodic nausea over the past 6-8 weeks, not obviously related to food or meals. She has had no vomiting or abdominal pain but has occasional indigestion. She usually has one bowel action per day, very occasionally loose.

She has put on 2-3 kg in the past month. Her weight had previously been fairly stable and she is upset about the weight gain as she prides herself on her appearance. She experienced a similar episode about 18 months ago that was investigated with an upper abdominal ultrasound (normal).

Further history

Liz says her periods have become a little more erratic but she has not had intercourse for 6 months so she is adamant she is not pregnant. On close questioning, she is eating about the same as always but consumes a bottle of white wine most nights except for Sundays. No specific foods trigger the nausea and she has no past history of indigestion or reflux. She admits that her bowel actions are a little looser if she drinks more than a bottle of wine. There is no blood or mucus in the bowel actions.

She feels more tense lately but has no history of panic attacks or binge eating. She feels her husband doesn't find her attractive anymore and is uninterested in more intimate relations, including intercourse. She doesn't believe he is having an affair but she is a little concerned that he seems very happy to go away on sales trips.

She has not been overseas in the past 12 months and has not consumed any bore or tank water in the past 6 months.

Diagnostic possibilities include gastro-oesophageal reflux disorder, anxiety, pregnancy, gall bladder disease, hazardous drinking, bulimia or a gastrointestinal infection such as giardia.

Answer 2

The likely cause of Liz's symptoms is high risk drinking. A bottle of white wine contains 6-8 standard drinks (Table 1). This equates to approximately 36-48 standard drinks per week.

Additional useful information includes:

Answer 3

Biological markers to assess alcohol consumption include:

Answer 4 Use the 5As framework.

Ask

Ask about drinking, including quantity, frequency and alcohol free days.

The amount of alcohol in each drink in outlined on page 15 of the RACGP SNAP guide.

Be alert to patient sensitivity about enquiry:

Assess

Assessment involves determining whether Liz is:

Interest in, or motivation to change can be determined by using both brief MI techniques and the decision balance (Table 2).

Ask Liz to rate her interest/ motivation to change on a scale from 1-10 where 1 = no interest in change and 10 = very interested in change. If she rates herself a 2-3, ask her what would need to a happen to raise the rating to an 8 or 9.

Similarly, ask Liz to rate her confidence to change on a scale from 1-10 where 10 = very confident in being able to change. If Liz rates herself 7-8, ask her why not a lower rating, eg. 3-4. This will give you some insight into the factors underpinning her confidence. If Liz rates herself 2-3, ask her what would need to happen to rate herself 9-10. Again, this provides insight into the conditions and strategies that will be necessary to assist her in being able to make changes.

Assist

Enlist support where possible. Identify high risk situations and work with patients to develop strategy to deal with them. Practice nurses with appropriate training and support are also a useful resource to assist patients in their efforts to moderate their drinking.

Provide written material on strategies to help with cutting down and dealing with negative emotions. Contact the local state drug and alcohol agency for resource materials (see SNAP guide, Page 23).

Arrange

Arrange follow up. Behaviour change takes time and replace is common. Regular review and ongoing support are key parts of the process. If patients are reluctant to return for regular review, remember to ask about how they are doing when they present for other reasons. Consider referral to a local drug and alcohol counsellor.