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You are the FY1 doctor at the local mental health ward. Mr Frank Haematuria has presented today to clinic, concerning a problem with his recent behaviour.

Please take a history from Frank and perform a mental state exam. You will then be asked to discuss the case with the examiner.

You are Frank Haematuria, a 62 year old gentleman who has come today because your daughter noticed that you have been acting differently for some time now. She does worry about your health more than you do these days – otherwise you definitely would not have come in. Hospitals are too much fuss – lots of loud beeping and rubbish food!

HPC: Your daughter told you that she first noticed that you had a problem about 6 months ago, but she was reluctant to say anything until now: she wanted you to have the ‘courage’ to confront the problem yourself. You did not notice a problem however, until you were in a car accident last week. Medically you were fine: just a few bruises, but you had had a drink before driving, first thing in the morning. This was the last straw and your daughter had to march you to the doctor’s to get checked out.

You have always been a drinker, although for the past year you have been drinking much more. You get through a 70cl bottle of whisky a day, although you are now finding that some days you have to have a few tins of strong lager on top of that to get the same effect. You find that you wake up in the morning and feel sick and shaky before you have a drink and that once you have started drinking you generally struggle to stop. It is often the first thing you think about in the morning. In fact, you have already had a drink today so that you could come to the appointment.

Your daughter is worried because you have had very little appetite so haven’t really been eating. You used to enjoy going to the dogs on a Saturday but now you can no longer afford the tickets and would rather stay in and drink. Your mood has been low for about the past year and you have been wanting to do the things you normally enjoy less and less, like going to the pub with your mates to play darts or going to the dogs. You have not had any thoughts of harming yourself or others, although you think you have probably haven’t been showering as much as you should or eating properly. At this point you think the smell might do some harm to the local wildlife!

ICE: You have been drinking more after your wife left you for another man and you were forced to move out of the family home. You know that your drinking has gotten out of control and you are worried because it might now be affecting your health. You have come because your daughter asked you to and was worried about you.

PMH: You had a heart attack in 2009. You have had no previous psychiatric illness.

FH: Your father died of brain cancer when you were very young. You do not think there is any history of liver problems. Your family have always been “drinkers”.

DH: You are supposed to take clopidogrel and ramipril after your heart attack, but you haven’t been collecting your prescriptions recently. You have no allergies.

SH: See above for alcohol history. You have smoked 20 cigarettes a day since the age of 16. You live alone in a bedsit after your wife left you for another man who she met at the bingo. It’s on the other side of town from where your daughter (age 30) and son (age 35) live so you don’t see them often. You have grandchildren but you have hardly seen them since the split and you are sad you’re missing out on seeing them. You used to work as a joiner before retiring last year. You were looking forward to spending your retirement with your wife and this is not how you had planned it would go at all.

You have never had any contact with the police. Your car accident was minor – you drove into a tree – so you drove off. This made your daughter more cross, as technically you’re a fugitive from the law!

Observe the student take a focussed alcohol history from the patient and ask the student to present an MSE for the patient.

Ask the student to formulate and present their differential diagnosis, which should include alcohol dependence. Topics for discussion: • What tools are available to assess alcohol use in patients? • What further medical investigations would you like to carry out in this patient? • List the features of alcohol dependency. • How could you manage this gentleman to help him cut down/stop drinking? • What risk factors for alcohol dependency does this patient exhibit?