Case 1: Mr. Smith
Provider
History
Mr. Smith is a 45–year–old businessman. He presents with epigastric pain and unrelenting nausea. His symptoms are intermittently relieved by over–the–counter antacids and H2 blockers. His work requires him to travel 3–4 nights per week. He has been particularly busy during the past month. His visit today is prompted by the fact that his symptoms are now interfering with his work.
Physical Exam
Blood Pressure 160/90 Heart Rate 80 and regular. He is not orthostatic. His abdomen has good Bowel Sounds, with mild tenderness in the epigastric region. His rectal exam reveals brown stool, guaiac negative.
Alcohol Screen
He drinks 3–4 days per week.
1–2 drinks at lunch and 2–4 drinks at dinner
(He drinks scotch and a little water)
You are concerned that he has gastritis and would like a trial of abstinence along with some medication and a follow–up with his primary care physician in 2 weeks. You also want him to know the safe limits of drinking once his gastritis is resolved.
Patient: Mr. Smith
You are a 45-year-old businessman. You have been very stressed out at work the past month. Normally you travel 3-4 nights per week, but this has increased lately, and you have had lots of deadlines. You are forced to eat out with business associates for lunch and dinner almost 3-4 days a week. You came to the ED today out of necessity. You have had increasing pain in your upper abdomen and constant nausea, which is affecting your ability to work. You have been taking Tums and Zantac over-the-counter sporadically, with brief periods of relief.
Alcohol history
Lately you have been drinking 1-2 drinks with lunch and 2-4 drinks with dinner. You drink scotch with a little water.
Negotiation
You are initially ambivalent about changing your drinking behavior. You choose a number 4.
Pros
All your associates have alcohol with meals and you do not want to stand out. Also, alcohol makes you relax with clients, and you think it gives you an edge with negotiating.
Cons
Your nausea and abdominal pain. You are also having more trouble than usual sleeping in hotel rooms. These are significant factors that once you realize they are directly related to drinking you are ready to take advice.
Your goal
After a discussion you agree to a trial of abstinence, and a return visit to your primary care doctor in 2 weeks. After a course of treatment you agree to try to stay within the safe drinking recommendations.