Maria

<div class="yourchoice">Meet Your Patient and History</div> <div class="container"> <div class="inner"> <div class="ehr"> <div class="header patientimg"> <h4>Patient Information</h4> <div class="patientname"></div> </div> <div class="content"><p><strong>Personal Hx:</strong> 47 year-old educational manager</p><p><strong>CC:</strong> Insomnia</p><p><strong>HPI:</strong> Patient's insomnia has increased over the last year. She has difficulty with both falling and staying asleep.</p><p><strong>Past Medical Hx:</strong> Annual visits for birth control medication. Upper respiratory tract infection last year and influenza 2 years ago.</p><p><strong>Medications:</strong> None on file. Past use of over-the-counter sleep medications with no success.</p></div> </div> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Hello, Ms. Garcia. It's nice to see you.</p> </div> <div class="patient-dialogue"> <p>Thank you.</p> </div> <div class="provider-dialogue"> <p>What have you been up to since I saw you a year ago?</p> </div> <div class="patient-dialogue"> <p> Oh, the usual. I'm still going to art openings and a few plays, but my insomnia has put a damper on going out and I feel too tired to do a lot of the social things I have always loved.</p> </div> </div> </div> <div class="navigation"> <div class="question"> To explore her chief complaint of insomnia, you:</div> <div class="continue">[[Ask about stress in her life]] </div> <div class="continue">[[Ask Ms Garcia to talk more about her insomnia]] </div> <div class="continue">[[Ask if the onset of insomnia coincided with a life change]]</div></div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask Ms. Garcia to talk more about her insomnia</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I'm sorry to hear that. Can you please tell me more about your insomnia?</p> </div> <div class="patient-dialogue"> <p>I have trouble falling asleep. Even if I do fall asleep, I wake up in the middle of the night and can't go back to sleep. I've tried over-the-counter sleep medications and warm milk, but they don't help. I'm frustrated with being tired all day because I can't sleep at night.</p> </div> <div class="provider-dialogue"> <p>That would be frustrating. Have you tried anything else to deal with your insomnia?</p> </div> <div class="patient-dialogue"> <p>I turn down the lights in the evening and I don't watch television before bed. I also try to limit my caffeine and avoid heavy meals late at night. The only thing that helps me go to sleep is some wine before bed.</p> </div> </div> </div> <div class="navigation"> <div class="question">Based on the information thus far, what would your next question be?</div> <div class="continue">[[Ask what finally made her come to see you]]</div> <div class="continue">[[Ask about the stress in her life]] </div> <div class="continue">[[Ask her to tell more about her alcohol consumption]]</div></div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Question - B</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask if the onset of insomnia coincided with a life change</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I see that you have been struggling with insomnia for a year. Did anything major happen in your life a year ago?</p> </div> <div class="patient-dialogue"> <p>I started a new job about a year ago, but I don't think my job is causing my insomnia. It can be stressful, but overall I enjoy my work. We just started virtual reality training for a college class, and that's been exciting.</p> </div> <div class="provider-dialogue"> <p>That does seem interesting. Can you think of anything else that might be contributing to your stress?</p> </div> <div class="patient-dialogue"> <p>Not sleeping at night is the main source of stress in my life. I lie in bed stressed and upset because I know I'm going to be so tired the next day. I'm not sure why I started having insomnia. Up until a year ago, I never had problems with sleep.</p> </div> </div> </div> <div class="navigation"> <div class="question">Based on the information thus far, what would your next question be?</div> <div class="continue">[[Ask her to tell you more about her insomnia]] </div> <div class="continue">[[Ask if she is willing to eliminate caffeine]] </div> <div class="continue">[[Ask what she does to relieve stress]]</div></div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Question - B</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask about stress in her life</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I'm sorry to hear you haven't been sleeping well. Please tell me about any stress in your life.</p> </div> <div class="patient-dialogue"> <p>My job can be stressful, but overall I enjoy my work. We just started virtual reality training for a college class, and that's been exciting. But not sleeping at night is the main source of stress in my life. I lie in bed stressed and upset because I know I'm going to be so tired the next day.</p> </div> </div> </div> <div class="navigation"> <div class="question"> What else would you ask to determine the cause of her chief complaint?</div> <div class="continue"> [[Ask how much caffeine she uses]] </div> <div class="continue">[[Ask her to talk about her insomnia some more]] </div> <div class="continue">[[Ask if she takes naps during the day]] </div></div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Question - A</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask how much caffeine she uses</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Caffeine can interfere with sleep. How much caffeine do you use?</p> </div> <div class="patient-dialogue"> <p>I'm careful not to have too much. Just a couple of cups of coffee a day, and a soda at lunch.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[History Summary A]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Discussion - A1</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> History Summary A</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To explore her chief complaint of insomnia, you:</div> <div class="response"><strong>You chose:</strong> Ask about stress in her life</div> Stress is a risk factor for sleep disturbances (Smagula et al., 2015). However, it would be better to get a full understanding of her insomnia, before asking about specific potential causes. Asking about her insomnia first would have given a broader understanding of the problem and revealed more about what Ms. Garcia thinks is a potential cause. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What else would you ask to determine the cause of her chief complaint?</div> <div class="response"><strong>You chose:</strong> Ask how much caffeine she uses</div> Caffeine intake is a relevant as it can impair sleep. However, it is still important to get a full understanding of her insomnia symptoms and what she perceives as a possible cause, before going through all the possible causes one-by-one. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Asking an open-ended question, one that addressed her insomnia and sleep hygiene directly, would have revealed that Ms. Garcia has trouble falling asleep unless she drinks some wine. She also wakes up and cannot go back to sleep resulting in daytime fatigue. She has tried turning down the lights in the evening, not watching television before bed, warm milk, over-ther-counter sleep aids, and drinking 1-2 glasses of wine before bed to help her sleep, but they did not help her insomnia. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Summary - A1a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> History Summary B</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To explore her chief complaint of insomnia, you:</div> <div class="response"><strong>You chose:</strong> Ask about stress in her life</div><p>While stress is a risk factor for sleep disturbances (Smagula et al., 2015), starting the discussion of her chief complaint by asking a more open-ended question about her insomnia would have revealed more about what is most important to her.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> What else would you ask to determine the cause of her chief complaint?</div> <div class="response"><strong>You chose:</strong> Ask her to talk about her insomnia</div><p>You recovered well by asking an open-ended question about her sleep problems next and learned that she has paid attention to a lot of factors involved in good sleep hygiene.</p></div> <div class="discussion"><strong>Regarding other possible choices:</strong> With a better start, you would have also learned that Ms. Garcia drinks 1-2 glasses of wine every night before bed to help her fall asleep. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Summary - A1b</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask if she takes naps during the day</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Do you ever nap during the day?</p> </div> <div class="patient-dialogue"> <p>I'm tired during the day, but I don't take naps.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[History Summary C]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Discussion - A3</p><div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> History Summary C</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To explore her chief complaint of insomnia, you</div> <div class="response"><strong>You chose:</strong> Ask about stress in her life</div><p>While stress is a risk factor for sleep disturbances (Smagula et al., 2015), it is a narrow question for a starting point. A broader, open-ended question might have revealed a more complete overview of Ms. Garcia's insomnia.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What else would you ask to determine the cause of her chief complaint?</div> <div class="response"><strong>You chose:</strong> Ask if she takes naps during the day</div> Also, asking about naps did not elicit any useful information and leaves out many questions that are important in a sleep assessment. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Asking a more open-ended question, one that addressed her insomnia and sleep hygiene directly, would have revealed that Ms. Garcia has trouble falling asleep unless she drinks some wine. She also wakes up and cannot go back to sleep resulting in daytime fatigue. She has tried turning down the lights in the evening, not watching television before bed, warm milk, over-ther-counter sleep aids, and drinking 1-2 glasses of wine before bed to help her sleep, but they did not help her insomnia. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Summary - A1c </p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her to talk about her insomnia some more</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Please tell me more about your insomnia.</p> </div> <div class="patient-dialogue"> <p>I'm able to fall asleep at night, but I wake up in the middle of the night and can't go back to sleep. I've tried over-the-counter sleep medications and warm milk, but they don't help. I'm frustrated with being tired all day because I can't sleep at night.</p> </div> <div class="provider-dialogue"> <p>That can be frustrating. Have you tried anything else to deal with your insomnia?</p> </div> <div class="patient-dialogue"> <p>I turn down the lights in the evening and I don't watch television before bed. I also avoid caffeine and heavy meals late at night. The only thing that helps me go to sleep is some wine before bed.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[History Summary B]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Discussion - A2</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her to tell you more about her insomnia</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Please tell me about your insomnia.</p> </div> <div class="patient-dialogue"> <p>I can fall asleep at night, but I wake up in the middle of the night and I can't go back to sleep. I've tried over-the-counter sleep medications and warm milk, but they don't help. I'm frustrated with being tired all day because I can't sleep at night.</p> </div> <div class="provider-dialogue"> <p>How else do you deal with your insomnia?</p> </div> <div class="patient-dialogue"> <p>I turn down the lights in the evening and I don't watch television before bed. I also avoid caffeine and heavy meals late at night. The only thing that helps me go to sleep is some wine before bed.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[History Summary G]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Discussion - C1</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask what finally made her come to see you</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I see you have been struggling with insomnia for about a year. What finally made you decide to see me?</p> </div> <div class="patient-dialogue"> <p>I'm reaching my breaking point with it. I just can't take it anymore.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[History Summary D]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Discussion - B1</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> History Summary D</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> To explore her chief complaint of insomnia, you:</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia to talk about her insomnia</div> Because insomnia is Ms. Garcia's chief complaint, asking her to talk about it after establishing rapport using an open-ended question was appropriate. Doing so gathered a lot of crucial information on her condition quickly. Open-ended questions often reveal what is most important or bothersome to the patient. </div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> Based on the information thus far, what would your next question be?</div> <div class="response"><strong>You chose:</strong> Ask what finally made her come to see you</div> The word "finally" holds an implicit judgment that she should have come to see you earlier. Being judgmental of patients usually has a negative impact on building rapport. Also, it is important to address her unhealthy reliance on wine to cope with stress. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Asking about her alcohol consumption would have revealed that Ms. Garcia drinks 1-2 glasses of wine every night before bed to help her fall asleep. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Summary - B1d </p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask about the stress in her life</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Can you tell me about the stress in your life?</p> </div> <div class="patient-dialogue"> <p>My job can be stressful, but overall I enjoy my work. We just started virtual reality training for a college class, and that's been exciting. But not sleeping at night is the main source of stress in my life. I lie in bed stressed and upset because I know I'm going to be so tired the next day.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[History Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Discussion- B2 </p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> History Summary E</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> To explore her chief complaint of insomnia, you</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia to talk about her insomnia</div> Because insomnia is Ms. Garcia's chief complaint, asking her to talk about it after establishing rapport was appropriate. Using an open-ended question led to her revealing a lot of crucial information on her condition quickly. Open-ended questions often yield the information that is most important or most bothersome to the patient. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Based on the information thus far, what would your next question be?</div> <div class="response"><strong>You chose:</strong> Ask about the stress in her life</div> While stress is a risk factor for sleep disturbances (Smagula et al., 2015), relying on alcohol (wine) every night rather than using healthier means of stress management is a concern. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Asking about substance use is part of a core assessment of insomnia (Hilty et al., 2009). Asking about her alcohol consumption would have revealed that Ms. Garcia drinks 1-2 glasses of wine every night before bed to help her fall asleep. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Summary - B2e</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> History Summary G</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To explore her chief complaint of insomnia, you:</div> <div class="response"><strong>You chose:</strong> Ask if the onset of insomnia coincided with a life change</div> This was a good question. Looking for a potential cause that coincides with the onset of symptoms is part of taking a good history. However, asking an open-ended question first would have yielded more information and provided a more complete overview of her insomnia. </div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Based on the information thus far, what would your next question be?</div> <div class="response"><strong>You chose:</strong> Ask her to tell you more about her insomnia</div> You recovered well by asking an open-ended question about her sleep problems and learned that she has paid attention to a lot of factors involved in good sleep hygiene including that she drinks wine to help her fall asleep. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Using an open-ended question to ask about her insomnia at the beginning of the appointment, would have revealed that Ms. Garcia drinks 1-2 glasses of wine every night before bed. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Summary - C1g</p><div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> History Summary F</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> To explore her chief complaint of insomnia, you:</div> <div class="response"><strong>You chose:</strong>Ask Ms. Garcia to talk more about her insomnia</div> Because insomnia is Ms. Garcia's chief complaint, asking her to talk about it after establishing rapport was appropriate. Using an open-ended question led to her revealing a lot of crucial information on her condition quickly. Open-ended questions often yield the information that is most important or most bothersome to the patient. </div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Based on the information thus far, what would your next question be?</div> <div class="response"><strong>You chose:</strong> Ask her to tell more about her alcohol consumption</div> Asking about her alcohol use was also a good choice because alcohol is a potential cause of insomnia. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Her insomnia is the main stress in her life right now. She is feeling "at the breaking point" with it.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Summary - B3f </p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask if she is willing to eliminate caffeine</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Are you willing to eliminate caffeine? Avoiding caffeine could help you sleep at night.</p> </div> <div class="patient-dialogue"> <p>I know that caffeine can cause insomnia, so I avoid it.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[History Summary H]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Discussion - C2</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> History Summary H</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To explore her chief complaint of insomnia, you:</div> <div class="response"><strong>You chose:</strong> Ask if the onset of insomnia coincided with a life change</div> This was a good question. Looking for a potential cause that coincides with the onset of symptoms is part of taking a good history. However, asking an open-ended question first would have yielded more information and provided a more complete overview of her insomnia. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Based on the information thus far, what would your next question be?</div> <div class="response"><strong>You chose:</strong> Ask if she is willing to eliminate caffeine</div> Caffeine intake is a relevant as it can impair sleep. However, it is still important to get a full understanding of her insomnia symptoms and what she perceives as a possible cause, before going through all the possible causes one-by-one. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Asking Ms. Garcia to talk about her insomnia first and asking about any measures she may have taken to resolve her insomnia, would reveal that Ms. Garcia is able to fall asleep at night but wakes up during the night and cannot go back to sleep. Ms. Garcia also reported daytime fatigue. To try to improve her sleep, she turns down the lights in the evening, does not watch television before bed, and drinks 1-2 glasses of wine every night before bed. Ms. Garcia has also tried warm milk and over the counter sleep medications, but they did not help her insomnia. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Summary - C2h</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask what she does to relieve stress</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>What do you do to relieve stress?</p> </div> <div class="patient-dialogue"> <p>I usually have some wine or call a friend.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[History Summary I]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Discussion - C3</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> History Summary I</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To explore her chief complaint of insomnia, you:</div> <div class="response"><strong>You chose:</strong> Ask if the onset of insomnia coincided with a life change.</div> This was a good question. Looking for a potential cause that coincides with the onset of symptoms is part of taking a good history. However, asking an open-ended question first would have yielded more information and provided a more complete overview of her insomnia. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Based on the information thus far, what would your next question be?</div> <div class="response"><strong>You chose:</strong> Ask what she does to relieve stress</div> While stress is a risk factor for sleep disturbances (Smagula et al., 2015), asking Ms. Garcia how she relieves stress jumps to exploring her response to eliminating a cause that has not been established. It would be better to fully explored her insomnia symptoms and history first. However, asking this question did reveal that Ms. Garcia consumes wine to help with stress, which is an important finding. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Had you directly addressed her insomnia and her efforts to resolve it, you would have learned that Ms. Garcia can fall asleep at night but wakes up during the night and cannot go back to sleep. Ms. Garcia also reported daytime fatigue. To try to improve her sleep, she avoids caffeine, turns down the lights in the evening, does not watch television before bed, and drinks 1-2 glasses of wine every night before bed. Ms. Garcia has also tried warm milk and over the counter sleep medications, but they did not help her insomnia. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Summary - C3I</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Differential Diagnosis</div> <div class="container"> <div class="inner"> <div class="note"><p>Next, you perform a physical exam on Ms. Garcia and inform her of the results. You will be asked to think about the differential diagnosis at that point.</p></div> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Your physical exam results are all within normal limits. I would also like to do some blood tests to further investigate possible causes of your insomnia.</p> </div> <div class="patient-dialogue"> <p> That sounds like a good idea.</p> </div> </div> </div> <div class="navigation"> <div class="question">Based on the information thus far, what is the most probable of the following diagnoses?</div> <div class="continue"> [[Insomnia due to alcohol use]] </div> <div class="continue">[[Insomnia due to undisclosed medication or substance use]]</div> <div class="continue">[[Insomnia due to illness]]</div></div> </div> <div class="footer"> <p class="small">You are here: Differential Diagnosis</p> <div class="chapter"><strong>Ch 2 |</strong> Differential Diagnosis</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Insomnia due to alcohol use</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I think your routine of drinking wine in the evenings is causing your insomnia.</p> </div> <div class="patient-dialogue"> <p>Why do you think that? If anything, the wine helps me fall asleep.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis Summary A]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Differential Diagnosis - Question - A</p> <div class="chapter"><strong>Ch 2 |</strong> Differential Diagnosis</div> <div class="chapter"><strong>Ch 2 |</strong> Differential Diagnosis</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Insomnia due to undisclosed medication or substance use</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>One possible cause of insomnia is taking something that keeps you awake, for example, things like food, drink, supplements, or medications. Even things like "natural herbal" supplements, nicotine, and decongestants can disrupt your sleep. Are you taking anything that could be keeping you awake at night? I appreciate you telling me even about drugs that may not be prescribed or legal. </p> </div> <div class="patient-dialogue"> <p>I don't take any of those things.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis Summary B]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Differential Diagnosis - Question - B</p> <div class="chapter"><strong>Ch 2 |</strong> Differential Diagnosis</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Insomnia due to illness</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Some medical problems, such as hyperthyroidism, restless leg syndrome, sleep apnea, and GERD can cause insomnia. You don't describe any symptoms of these problems, but I'm going to run some tests to make sure they aren't a factor.</p> </div> <div class="patient-dialogue"> <p>Okay.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Differential Diagnosis Summary C]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Differential Diagnosis - Question - C</p> <div class="chapter"><strong>Ch 2 |</strong> Differential Diagnosis</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong>Differential Diagnosis Summary A</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> Based on the information thus far, what is the most probable of the following diagnoses?</div> <div class="response"><strong>You chose:</strong> Insomnia due to alcohol use</div> Insomnia secondary to alcohol use is the most likely diagnosis among these choices. Although alcohol can promote the onset of sleep in people with insomnia, it tends disrupt the second phase of sleep and cause nighttime wakefulness (NIAAA, 1998). Individuals who rely on alcohol to fall asleep at night are also more likely to report daytime sleepiness (Stein & Friedman, 2005). Ms. Garcia reported consuming 1-2 glasses of wine each night before bed. Thus, this is the most likely cause of her insomnia. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> It is important to consider the possibility that she is taking something that might keep her awake, such as a supplement or over the counter medication. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Evaluation Screening and Assessment]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Differential Diagnosis - Summary - A1</p> <div class="chapter"><strong>Ch 2 |</strong> Differential Diagnosis</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Differential Diagnosis Summary B</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Based on the information thus far, what is the most probable of the following diagnoses?</div> <div class="response"><strong>You chose:</strong> Insomnia due to undisclosed medication or substance use</div> It is important to consider the possibility that she is taking something that might keep her awake, such as a supplement or over the counter medication. However, there is no evidence of this so far. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> At this point, the most likely differential diagnosis is insomnia secondary to alcohol consumption. Alcohol can promote the onset of sleep in people with insomnia, but it tends to disrupt the second phase of sleep and cause nighttime wakefulness (NIAAA, 1998). Individuals who rely on alcohol to fall asleep at night are also more likely to report daytime sleepiness (Stein & Friedman, 2005). The effects of alcohol on sleep can vary from patient to patient (NHLBI, 1999). So Ms. Garcia's 2 glasses of wine could be contributing to her insomnia. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Evaluation Screening and Assessment]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Differential Diagnosis - Summary - B1</p> <div class="chapter"><strong>Ch 2 |</strong> Differential Diagnosis</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Differential Diagnosis Summary C</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Based on the information thus far, what is the most probable of the following diagnoses?</div> <div class="response"><strong>You chose:</strong> Insomnia due to illness</div> Because she has no symptoms suggestive of other conditions that might cause insomnia, this is not the most likely diagnosis of the differential diagnosis choices given. A blood test to rule out hyperthyroidism might be considered, especially if there are any other symptoms of that condition. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> At this time, the most likely differential diagnosis is insomnia secondary to alcohol use. Alcohol can promote the onset of sleep in people with insomnia, but it tends disrupt the second phase of sleep and cause nighttime wakefulness (NIAAA, 1998). Individuals who rely on alcohol to fall asleep at night are also more likely to report daytime sleepiness (Stein & Friedman, 2005). The effects of alcohol on sleep can vary from patient to patient (NHLBI, 1999), so just 2 glasses of wine could be affecting her sleep. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Evaluation Screening and Assessment]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Differential Diagnosis - Summary - C1</p> <div class="chapter"><strong>Ch 2 |</strong> Differential Diagnosis</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> No need of further alcohol screening</div> <div class="container"> <div class="inner"> <div class="note">Ms. Garcia actually does need further alcohol screening, as she has indicated some incidents of high-level alchol use.</div></div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Evaluation Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: NIAAA Screening and Assessment - Question - B</p> <div class="chapter"><strong>Ch 3 |</strong> NIAAA Screening and Assessment</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Further screening for alcohol use disorder</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Has your drinking ever led you to having an accident or bodily harm or trouble with the law?</p> </div> <div class="patient-dialogue"> <p>No, nothing like that.</p> </div> <div class="provider-dialogue"> <p>Relationship or work problems? </p> </div> <div class="patient-dialogue"> <p>No.</p> </div> <div class="provider-dialogue"> <p>Do you find you are drinking more to get the same effect?</p> </div> <div class="patient-dialogue"> <p>No. It's always one to two glasses. I stick with that limit.</p> </div> <div class="provider-dialogue"> <p>Have you found that you experience withdrawal when you don't drink?</p> </div> <div class="patient-dialogue"> <p>I've never really quit drinking, but I don't think I would go into withdrawal if I did quit.</p> </div> <div class="provider-dialogue"> <p>Do you keep drinking despite it causing problems?</p> </div> <div class="patient-dialogue"> <p>No it really doesn't cause any problems. <i>[She's beginning to sound irritated.]</i></p> </div> <div class="provider-dialogue"> <p>Do you spend significant time drinking?</p> </div> <div class="patient-dialogue"> <p>No.</p> </div> <div class="provider-dialogue"> <p>Do you prioritize alcohol over more important matters?</p> </div> <div class="patient-dialogue"> <p>No. I go about my day and then I relax with some wine at night.</p> </div></div> <div class="note"> In summary, Ms. Garcia screened negatively for needing further alcohol assessment. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Evaluation Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: NIAAA Screening and Assessment - Question - A</p> <div class="chapter"><strong>Ch 3 |</strong> NIAAA Screening and Assessment</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> She is a binge drinker</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Based on your answers to the screening questions, I'm concerned you may be a binge drinker.</p> </div> <div class="patient-dialogue"> <p>I told you, the incident at the wedding was a one-time occasion. It hardly means that I'm a binge drinker. You are making it seem like I get drunk every night when I don't.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Evaluation Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: NIAAA Screening and Assessment - Question - C</p> <div class="chapter"><strong>Ch 3 |</strong> NIAAA Screening and Assessment</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Evaluation Summary A</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> Given her answers, how would you assess Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Further screening for alcohol use disorder</div> The NIAAA screening tool says to continue screening if, for women, there is one or more episodes of 4 or more drinks in a year. Ms. Garcia's response that there was one such episode indicated a need to assess for alcohol use disorder. However, the single episode was atypical for her, so you might consider ignoring it. If you did no further assessment, you would not have learned that she drinks 9 glasses of wine per week which exceeds the recommended limit for women of 7 drinks per week. <br/> Because she does exceed recommended drinking limits, a brief intervention for at-risk drinking is indicated. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> She rarely engages in binge drinking.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Brief Intervention]]</div> </div> </div> <div class="footer"> <p class="small">You are here: NIAAA Screening and Assessment - Summary - A1</p> <div class="chapter"><strong>Ch 3 |</strong> NIAAA Screening and Assessment</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Evaluation Summary B</div> <div class="container"> <div class="inner"> <div class="feedback incorrect"> <div class="question"><strong>Question 1:</strong> Given her answers, how would you assess Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> No further screening for alcohol use disorder needed</div> Incorrect. Ms. Garcia's responses to the initial screening questions indicated a need to screen her further for alcohol use disorder by virtue of having at least one episode of consuming 4 or more drinks on one occasion.</div> </div> <div class="navigation"> <div class="question"> Continue to:</div> <div class="continue">[[Evaluation Dialogue]]</div> </div> </div> <div class="footer"> <p class="small">You are here: NIAAA Screening and Assessment - Summary - B1</p> <div class="chapter"><strong>Ch 3 |</strong> NIAAA Screening and Assessment</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Evaluation Summary C</div> <div class="container"> <div class="inner"> <div class="feedback incorrect"> <div class="question"><strong>Question 1:</strong> Given her answers, how would you assess Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> She is a binge drinker</div> Binge drinking is defined as a pattern of drinking enough to reach a blood alcohol concentration (BAC) of 0.08% or higher. Women can usually achieve a BAC of 0.08% if they drink 4 or more drinks within 2 hours (CDC, 2015). While, Ms. Garcia may have achieved a BAC of 0.08% or higher at the wedding, this one occasion does not constitute a pattern. Therefore, Ms. Garcia is not a binge drinker. At most, she engaged in an episode of binge drinking.</div> </div> <div class="navigation"> <div class="question"> Continue to:</div> <div class="continue">[[Evaluation Dialogue]]</div> </div> </div> <div class="footer"> <p class="small">You are here: NIAAA Screening and Assessment - Summary - C1</p> <div class="chapter"><strong>Ch 3 |</strong> NIAAA Screening and Assessment</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Brief Intervention</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I am concerned because your average of 9 drinks per week is a little higher than the limit of 7, which is recommended to be healthy. I also think your drinking is contributing to your insomnia. Putting those two things together, I recommend cutting back on your drinking. Can we talk about that?</p> </div> <div class="patient-dialogue"> <p>I'll keep that in mind. Now can we move on to my insomnia? What can I do to sleep at night? I don't think cutting back the drinks will solve my insomnia problem.</p> </div> </div> </div> <div class="navigation"> <div class="question">Which of the following treatment options would you recommend to Ms. Garcia?</div> <div class="continue">[[Recommend reduced alcohol and other sleep hygiene]] </div> <div class="continue">[[Prescribe zolpidem]] </div> <div class="continue">[[Begin a regular exercise program]]</div> </div></div> <div class="footer"> <p class="small">You are here: Brief Intervention and Treatment</p> <div class="chapter"><strong>Ch 4 |</strong> Brief Intervention and Treatment</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Recommend reduced alcohol and other sleep hygiene</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>You have already tried some techniques to help you sleep, such as turning down your lights and avoiding heavy meals in the evening, not watching television before bed, limiting caffeine. Techniques like these, sometimes called sleep hygiene, are important. Some others that might help include daytime exercise, further reductions in caffeine, avoiding chocolate and other stimulants, darkening the bedroom, and stress management techniques such as meditation and therapy, and reducing alcohol intake.</p> </div> <div class="patient-dialogue"> <p>I don't want to give up my wine. It helps me to relieve stress and fall asleep. </p> </div> <div class="provider-dialogue"> <p>I understand that wine helps you relax. However, alcohol can disrupt your sleep. I think for your insomnia and general health it would be best to quit drinking. Quitting drinking will also prevent you from developing alcohol use disorder.</p> </div> <div class="patient-dialogue"> <p>There has to be something else you can do to help me sleep. Isn't there some sort of medication you can give me to sleep?</p> </div> <div class="provider-dialogue"> <p>The other ways I mentioned earlier, sleep hygiene, will also help you sleep. Can you try to work on them and at least entertain the idea of cutting back on your alcohol use, say to just one drink per night and see how it affects your sleep? I think it will make a difference.</p> </div> <div class="patient-dialogue"> <p>What about a medication, though?</p> </div> <div class="provider-dialogue"> <p>In a way, alcohol has become your "medication" to help you sleep, but it's having the opposite effect. I recommend that you first stop using alcohol to help you sleep and attend to sleep hygiene instead and see if that helps. If that does not help, we can consider other interventions.</p> </div> <div class="patient-dialogue"> <p>I guess that makes sense. </p> </div> <div class="provider-dialogue"> <p>Would you be willing to quit drinking to see how it impacts your sleep?</p> </div> <div class="patient-dialogue"> <p>I suppose I can give it a try. I need to be able to sleep at night.</p> </div> </div> </div> <div class="navigation"> <div class="question"> Continue to:</div> <div class="continue">[[Brief Intervention Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Brief Intervention and Treatment - Question - A</p> <div class="chapter"><strong>Ch 4 |</strong> Brief Intervention and Treatment</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Prescribe zolpidem</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>If you like, I can prescribe zolpidem. It is a medication that can help you sleep at night. Only take the zolpidem if you have time to sleep for 7-8 hours and don't take the medication if you have been drinking. If the medication is not enough to help you sleep, you may need to take additional measures to help you sleep.</p> </div> <div class="patient-dialogue"> <p>I'll definitely take the medication. I need to sleep at night.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Brief Intervention Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Brief Intervention and Treatment - Question - B</p> <div class="chapter"><strong>Ch 4 |</strong> Brief Intervention and Treatment</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Begin a regular exercise program</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Do you exercise on a regular basis?</p> </div> <div class="patient-dialogue"> <p>No, I've been too tired to exercise. Does this have anything to do with my sleeping? Exercise wakes me up!</p> </div> <div class="provider-dialogue"> <p>Gentle exercise early in the day, or before dinner, is an effective nonpharmacological treatment for insomnia. Start with something you enjoy and gradually increase the intensity.</p> </div> <div class="patient-dialogue"> <p>What if an exercise program isn't enough to help me sleep?</p> </div> <div class="provider-dialogue"> <p>I certainly want to talk about other things that I think will help you sleep. For now, would you consider getting some more exercise during the day?</p> </div> <div class="patient-dialogue"> <p>I suppose.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Brief Intervention Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Brief Intervention and Treatment - Question - C</p> <div class="chapter"><strong>Ch 4 |</strong> Brief Intervention and Treatment</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Brief Intervention Summary A</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> Which of the following brief intervention options would you recommend to Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Recommend reduced alcohol and other sleep hygiene</div> Advising Ms. Garcia to quit drinking was appropriate given its health risks and potential as a significant contributor to her insomnia. Furthermore, reframing the problem was a good way to work with Ms. Garcia. This helped her agree to try to quit drinking. Quitting drinking is a necessary component of treating her insomnia and improving her health. Addressing the most likely root causes of her insomnia takes the approach of using healthy, low-risk behaviors as a diagnostic treatment. If she responds, it will confirm the diagnosis of insomnia secondary to poor sleep hygiene, especially excess alcohol. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> It is too early to be prescribing sleep medication without having completed evaluation and diagnosis of her sleep problem. In response to being given a prescription for a sleep aide at this point, Ms. Garcia, would have lost interest in addressing her alcohol use problem. She was somewhat resistant to exercising more as a way to address her insomnia, but did agree to try it.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Followup Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Brief Intervention and Treatment - Summary - A1</p> <div class="chapter"><strong>Ch 4 |</strong> Brief Intervention and Treatment</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Brief Intervention </div> <div class="container"> <div class="inner"> <div class="feedback incorrect"> <div class="question"><strong>Question 1:</strong> Which of the following treatment options would you recommend to Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Prescribe zolpidem</div> This would be jumping to a treatment without completing a full evaluation and diagnosis of her sleeping problem. Zolpidem is an FDA approved medication for the treatment of insomnia (Lei et al., 2015). Even though you advised her not to take the zolpidem if she has been drinking, it is not advisable to prescribe this medication to someone who drinks every night and is not committed to quitting drinking. This approach does not address the root cause of her insomnia which is her alcohol use. She wanted an easy fix, and once she felt she had one, she was out the door. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> The best approach would include advising Ms. Garcia to reduce or quit drinking and working with her resistance by reframing the problem. Prescribing sleep hygiene would be important at this point, including daytime exercise, further reductions in caffeine, avoiding chocolate and other stimulants, darkening the bedroom, and stress management techniques such as meditation and therapy. This strategy would have led to Ms. Garcia agreeing to try to quit drinking. Quitting drinking is a necessary component of treating her insomnia and improving her health. Addressing the most likely root causes of her insomnia takes the approach of using healthy, low-risk behaviors as a diagnostic treatment. If she responds, it will confirm the diagnosis of insomnia secondary to poor sleep hygiene, especially excess alcohol. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Followup Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Brief Intervention and Treatment - Summary - B1</p> <div class="chapter"><strong>Ch 4 |</strong> Brief Intervention and Treatment</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Brief Intervention Summary C</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Which of the following treatment options would you recommend to Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Begin a regular exercise program</div> While daytime exercise is an effective, nonpharmacologic treatment for insomnia (Ramakrishnan & Scheid, 2007), it should be recommended in combination with other recommendations for good sleep hygiene. Instituting an exercise program does not address alcohol's contribution to Ms. Garcia's insomnia, nor its other health effects. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> <p>The best approach would include advising Ms. Garcia to quit drinking and working with her resistance by reframing the problem. Quitting drinking is a necessary component of treating her insomnia and improving her health.</p> <p>Treatment also should include adding lots of other supports for sleep, such as daytime exercise, further reductions in caffeine, avoiding chocolate and other stimulants, darkening the bedroom, and stress management techniques such as meditation and therapy. This strategy would have led to Ms. Garcia agreeing to try to quit drinking. It is too early to be prescribing a sleep aid, since her sleep problem has not been fully evaluated and diagnosed. Addressing the most likely root causes of her insomnia takes the approach of using healthy, low-risk behaviors as a diagnostic treatment. If she responds, it will confirm the diagnosis of insomnia secondary to poor sleep hygiene, especially excess alcohol.</p></div></div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Followup Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Brief Intervention and Treatment - Summary - C1</p> <div class="chapter"><strong>Ch 4 |</strong> Brief Intervention and Treatment</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Followup Plan</div> <div class="container"> <div class="inner"> <div class="note"><em>[By the end of the appointment, Maria has agreed to try making several lifestyle changes to improve her sleeping.]</em></div> <div class="dialogue-container"> <div class="provider-dialogue"> <p>So, the plan is that you are going to quit drinking and see if that resolves your insomnia.</p> </div> <div class="patient-dialogue"> <p>I'll give it a try, but at the same time I'm still not sure that my wine is causing my insomnia.</p> </div> <div class="provider-dialogue"> <p>I am glad you are willing to quit drinking and follow the other guidelines to see if that helps before trying adding in more drastic measures like sleeping pills that can have adverse side effects. If this doesn't work, then we'll look at some alternative approaches. Here is some literature that will help you remember all we've talked about. I'd like you to schedule a followup appointment.</p> </div> </div> </div> <div class="navigation"> <div class="question">When would you recommend that Ms. Garcia return to your office for a followup visit?</div> <div class="continue">[[One week]] </div> <div class="continue">[[One month]] </div> <div class="continue">[[One month if abstinence does not resolve her insomnia]]</div></div> </div> <div class="footer"> <p class="small">You are here: Follow Up Plan</p> <div class="chapter"><strong>Ch 5 |</strong> Follow Up Plan</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> One week</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I would like to have you come back in a week so we can talk about your test results and check in on your progress. Could you make an appointment before you leave?</p> </div> <div class="patient-dialogue"> <p>Okay. I guess I'll see you in a week.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Followup Plan Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Follow Up Plan - Question - A</p> <div class="chapter"><strong>Ch 5 |</strong> Follow Up Plan</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> One month</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I'd like to check in with you in a month. Please make an appointment before you leave today.</p> </div> <div class="patient-dialogue"> <p>Thanks, I appreciate that. I'll make that appointment. I hope to be sleeping by the time I see you again.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Followup Plan Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Follow Up Plan - Question - B</p> <div class="chapter"><strong>Ch 5 |</strong> Follow Up Plan</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> One month if abstinence does not resolve her insomnia</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Let's have you try this for a month. If you are not doing better by then, you could call for another appointment.</p> </div> <div class="patient-dialogue"> <p>Oh, okay.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Followup Plan Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Follow Up Plan - Question - C</p> <div class="chapter"><strong>Ch 5 |</strong> Follow Up Plan</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Followup Plan Summary A</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> When would you recommend that Ms. Garcia return to your office for a followup visit?</div> <div class="response"><strong>You chose:</strong> One week</div><p>One week is a good time frame to schedule a followup appointment with Ms. Garcia, given her alcohol consumption, the extent to which she is troubled by her insomnia, and her pending lab results. It was also important that you asked her to make her followup appointment before leaving your office. This increases her chances of attending them.</p><p> Even though she will return to your office in a week, you need to contact Ms. Garcia if her lab results indicate an urgent problem.</p></div> <div class="discussion"><strong>Regarding other possible choices:</strong> Since she has described being at a breaking point with her insomnia and struggles already with using too much alcohol, it is important to followup in a timely manner. A month would be too long.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment One Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Follow Up Plan - Summary - A1a</p> <div class="chapter"><strong>Ch 5 |</strong> Follow Up Plan</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Followup Plan Summary B</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> When would you recommend that Ms. Garcia return to your office for a followup visit?</div> <div class="response"><strong>You chose:</strong> One month</div> One month is too long time, given the excessive amount that Ms. Garcia drinks, her level of distress over her insomnia, and the pending results of her blood tests. Scheduling a visit today was a good approach as she would be more likely to come back. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> <p>Scheduling a followup appointment for the next week before leaving the office is indicated. Establishing and maintaining abstinence is a difficult process. Assuring support for Ms. Garcia during this process is important.</p><p>If one week followup appointment is not feasible, you could have the nurse call to check in with Ms. Garcia. A phone call from the nurse increases the chances that Ms. Garcia would return to your office if she cannot quit drinking or is still struggling with insomnia.</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment One Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Follow Up Plan - Summary - B1</p> <div class="chapter"><strong>Ch 5 |</strong> Follow Up Plan</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Follow Up Plan Summary C</div> ======= <p class="small">You are here: Followup Plan - Summary - B1</p> <div class="chapter"><strong>Ch 5 |</strong> Followup Plan</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> <div class="chaptermark4"></div> <div class="chaptermark5"></div> <div class="chaptermark6"></div> </div> </div>

<div class="yourchoice"><strong>You chose:</strong> Followup Plan Summary C</div> <div class="container"> <div class="inner"> <div class="feedback incorrect"> <div class="question"><strong>Question 1:</strong> When would you recommend that Ms. Garcia return to your office for a followup visit?</div> <div class="response"><strong>You chose:</strong> One month only if abstinence does not resolve her insomnia</div> One month is a long time, given the excessive amount that Ms. Garcia drinks, her level of distress over her insomnia, and the pending results of her blood tests. Also, scheduling a visit today, she would be more likely to come back. Asking her to return to your office only if her insomnia does not resolve with abstinence fails to provide her with the followup care she needs. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> <p>Scheduling a follow-up appointment for the next week before leaving the office is indicated. Establishing and maintaining abstinence is a difficult process; assuring support for Ms. Garcia during this process is important.</p><p>If a one week follow-up appointment is not feasible, you could have the nurse call to check in with Ms. Garcia. A phone call from the nurse increases the chances that Ms. Garcia would return to your office if she cannot quit drinking or if she was still struggling with insomnia.</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment One Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Follow Up Plan - Summary - C1</p> <div class="chapter"><strong>Ch 5 |</strong> Follow Up Plan</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Appointment One Summary</div> <div class="container"> <div class="inner"> <div class="summary"><p><strong>Patient Info/CC/HPI (Subjective):</strong> 47 yowf complains of insomnia, with alcohol use as an apparent contributing factor. Has not tried prescription sleep medications, but non-responsive to OTC sleep aids. Has not tried several other lifestyle changes that could help support better sleep.</p><p><strong>P.E./Labs/Meds (Objective):</strong> All physical exam findings were within normal limits and lab results are pending.</p><p><strong>Working Diagnoses:</strong><ol><li>Insomnia secondary to alcohol use and stress.</li><li>Rule out medical causes of insomnia (labs pending)<li>At risk for alcohol use disorder</li></ol></p></div> <div class="summary"><strong>Brief interventions/Treatment (Plan):</strong><ol><li>Trial of alcohol abstinence</li><li>Other lifestyle changes to support sleep, including daytime exercise, evening meditation and stretching to reduce stress, use of darkness before and during bedtime</li><li>Labs to rule out medical cause for insomnia</li><li>Followup plan: Re-evaluate in 1 week.</li></ol></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two]]</div> </div> </div> <div class="footer"> <p class="small">You are here: - Appointment One Summary</p> <div class="chapter"><strong>Ch 5 |</strong> Follow Up Plan</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two</div> <div class="container"> <div class="inner"> <div class="summary"><p><strong>Patient Information:</strong> 47 year old educational manager</p><p><strong>Chief Complaint:</strong> 1 week follow up for insomnia</p><p><strong>History of Present Illness:</strong> Factors presumed to contribute to insomnia, excessive alcohol use and stress, treated with lifestyle changes for one week (abstain from alcohol, adopt stress management behaviors). Liver enzymes from one week ago were mildly elevated, consistent with excess alcohol intake. Thyroid tests (TSH) and blood panel otherwise within normal limits.</p><p><strong>Past Medical History:</strong> Recent visit for insomnia and brief interventions for excess alcohol use and stress management require followup evaluation. Annual visits for birth control medication. An upper respiratory tract infection last year and influenza 2 years ago.</p><p><strong>Medications:</strong> No prescriptions on file. Past, but not current use of OTC sleep aids.</p></div> <div class="results"><p><strong>Laboratory:</strong> Significant results from last week</p><ul><li>MCV 104 (fL)/80-100 (fL)</li><li>Elevated MCV</li></ul><p><strong>Comprehensive Metabolic Panel:</strong></p><ul><li>AST (SGOT) 46 (U/L)/0-42 (U/L)</li></ul></div></div> <div class="navigation"> <div class="question">You want to address the chief reasons for this appointment. How would you begin?</div> <div class="continue">[[Observe Ms. Garcia for obvious signs of fatigue]] </div> <div class="continue">[[Ask Ms. Garcia to update you on her sleep hygiene and alcohol consumption and sleep]] </div> <div class="continue">[[Talk about the lab results]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Observe Ms. Garcia for obvious signs of fatigue</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="patient-dialogue"> <p> Good afternoon. <em>[Ms. Garcia is a bit slouched in the chair. She is wearing makeup, but you can tell there are dark circles under her eyes.]</em></p> </div> <div class="provider-dialogue"> <p> Good afternoon, Ms. Garcia. I am glad you came back for a followup visit.</p> </div> <div class="patient-dialogue"> <p> Well, I think we have some issues to discuss.</p> </div> </div></div> <div class="navigation"> <div class="question">What else would you like to discuss with Ms. Garcia at this point?</div> <div class="continue">[[Talk about the blood tests]]</div> <div class="continue">[[Tell her she looks like she is not sleeping well]] </div> <div class="continue">[[Ask her what she needs to discuss]]</div></div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Question - A</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask Ms. Garcia to update you on her sleep hygiene and alcohol consumption and sleep</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I am glad to see you again. Can you please update me on how your efforts to sleep better are going as well as your efforts to eliminate alcohol?</p> </div> <div class="patient-dialogue"> <p>Honestly, I've had trouble cutting back on the alcohol. I know I said I'd quit drinking, but it wasn't as easy as I thought it would be. I was pretty disappointed in myself and thought if I couldn't manage something as simple as that, why bother with trying any of the other things we talked about. So, my insomnia hasn't improved. I'm still tossing and turning half the night.</p> </div> <div class="provider-dialogue"> <p>I am sorry to hear that. We can talk about things to do to make quitting alcohol easier.</p> </div> </div> </div> <div class="navigation"> <div class="question">How do you want to learn more at this point?</div> <div class="continue"> [[Discuss lab results]] </div> <div class="continue">[[Talk about alternative treatments]] </div> <div class="continue">[[Ask why she was unable to stop drinking]]</div></div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Question - B</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Talk about the lab results</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>The blood tests from your last appointment did not show any medical causes for your insomnia. Your thyroid test was normal.</p> </div> <div class="patient-dialogue"> <p>Good.</p> </div> <div class="provider-dialogue"> <p>While that is encouraging, some test results, your liver enzymes and your red blood cell size, were a little high. They suggest you may be drinking more than we originally discussed.</p> </div> <div class="patient-dialogue"> <p>Well, maybe I'd been having 3 glasses of wine before bed sometimes.</p> </div> </div> </div> <div class="navigation"> <div class="question">How do you want to further address the main reasons for this appointment?</div> <div class="continue">[[Ask her what she wants to discuss now]] </div> <div class="continue">[[Ask if she has stopped drinking and how she is sleeping]] </div> <div class="continue">[[Ask her to be honest with you]]</div> </div></div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Question - C</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Talk about the blood tests</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>The blood tests from your last appointment didn't show any medical causes for your insomnia. Your thyroid test was normal.</p> </div> <div class="patient-dialogue"> <p>Good. I guess.</p> </div> <div class="provider-dialogue"> <p>While that is encouraging, some test results, your liver enzymes and your red blood cell size, were a little high and suggest you may be drinking more than we originally discussed.</p> </div> <div class="patient-dialogue"> <p> Well, maybe it's more like 3 glasses of wine before bed sometimes.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Discussion - A2</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her she looks like she is not sleeping well</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>You look like you are not sleeping well.</p> </div> <div class="patient-dialogue"> <p>Gee, thanks. I didn't know I looked that bad. But, you're right, I haven't slept well. I'm still tossing and turning half the night.</p> </div> <div class="provider-dialogue"> <p>I am sorry to hear that. I was hoping that your insomnia would have resolved by now.</p> </div> <div class="patient-dialogue"> <p> Me, too. Although, I haven't really done any of the things we talked about.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two - Discussion - A1</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her what she needs to discuss</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>What would you like to discuss with me?</p> </div> <div class="patient-dialogue"> <p>I'm still not sleeping at night. As the weeks go by I'm feeling more and more run-down. I don't know how much more of this I can take.</p> </div> <div class="provider-dialogue"> <p>I'm sorry to hear that. How did it go with reducing you alcohol intake? Were you able to do that? </p> </div> <div class="patient-dialogue"> <p>Honestly, I've had trouble cutting back on the alcohol. It was not as easy as I thought it would be.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Discussion - A3</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Discuss lab results</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>The blood tests from your last appointment did not show any medical causes for your insomnia. Your thyroid test was normal.</p> </div> <div class="patient-dialogue"> <p>Good.</p> </div> <div class="provider-dialogue"> <p>While that is encouraging, some test results, your liver enzymes and your red blood cell size, were a little high. They suggest you may be drinking more than we originally discussed.</p> </div> <div class="patient-dialogue"> <p>Well, maybe it was more like 3 glasses of wine before bed.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two Summary D]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Discussion - B1</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two Summary A</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> You want to address the chief reasons for this appointment. How would you begin?</div> <div class="response"><strong>You chose:</strong> Observe Ms. Garcia for obvious signs of fatigue</div><p>It is good that you followed up on the insomnia and it is also important to observe patients for physical signs related to the problem you are evaluating.</p></div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> What else would you like to discuss with Ms. Garcia at this point?</div> <div class="response"><strong>You chose:</strong> Tell her she looks like she is not sleeping well</div><p>This statement offended Ms. Garcia because it made an assumption based on an observation and also was a negative evaluation of her appearance. Instead, the observation could have been confirmed with a question about her sleep.</p></div> <div class="discussion"><strong>Regarding other possible choices:</strong> <p>Discussing Ms. Garcia's lab results was important to inform her that she has slightly elevated liver enzymes and MCV, which suggests she is drinking more than she revealed. She would have admitted that she had actually been consuming 3 glasses of wine before bed each night.</p><p> Asking directly about her efforts to cut back on drinking and improve her sleep hygiene habits would have led to learning that quitting drinking was harder than she thought. She was so dismayed about this, she was unable to change her sleep hygiene habits. In response, you could have introduced the topic of alcohol use treatment.</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Summary - A1a</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her to be honest with you</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I need you to be honest with me from now on. The only way I can help you with this problem is if I understand the full extent of your alcohol use, as difficult as that may be to talk about.</p> </div> <div class="patient-dialogue"> <p>I didn't want you to make a big deal over my drinking. I just wanted you to focus on my sleep.</p> </div> <div class="provider-dialogue"> <p>I understand your reservations. However, in order for me to treat you effectively, I need you to be honest with me so we can work together to find a resolution to your alcohol use and insomnia.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two Summary G]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Discussion - C1</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask if she has stopped drinking and how she is sleeping</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Did you quit drinking this past week?</p> </div> <div class="patient-dialogue"> <p>Honestly, I've had trouble cutting back on alcohol. I knew I needed to quit, but it was not as easy as I thought it would be.</p> </div> <div class="provider-dialogue"> <p>Okay. We can talk about ways to help you with that. How is your insomnia?</p> </div> <div class="patient-dialogue"> <p>I still toss and turn most of the night. I'm just exhausted from not sleeping. I got dismayed about not being able to quit drinking and so I haven't really done any of the other things we talked about.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two Summary H]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Discussion - C2</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask why she was unable to stop drinking</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Why were you unable to stop drinking?</p> </div> <div class="patient-dialogue"> <p>I don't know. Like I said, I tried.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Discussion - B3</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

======= <p class="small">You are here: Maria Garcia Appointment Two - Discussion - B3</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> <div class="chaptermark4"></div> <div class="chaptermark5"></div> <div class="chaptermark6"></div> </div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her what she wants to discuss now</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>What do you want to discuss now?</p> </div> <div class="patient-dialogue"> <p>Um, do you mean like about my sleep? I still can't sleep. I really need something to help with that.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two Summary I]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Discussion - C3</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two Summary B</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> You want to address the chief reasons for this appointment. How would you begin?</div> <div class="response"><strong>You chose:</strong> Observe Ms. Garcia for obvious signs of fatigue</div> It is good that you followed up on the insomnia and it is also important to observe patients for physical signs related to the problem you are evaluating.</div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> >What else would you like to discuss with Ms. Garcia at this point?</div> <div class="response"><strong>You chose:</strong> Talk about the blood tests</div> It was important to address the lab test results. In particular, describing the elevated liver enzymes and increased MCV was important as these are markers for chronic excessive intake of alcohol. As a result, you learned that Ms. Garcia drinks more than she had admitted at her first appointment, as much as 21 glasses of wine per week. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Asking directly about her efforts to cut back on drinking and improve her sleep hygiene habits would have revealed that quitting drinking was harder than she thought. She was so dismayed about this, she was unable to change her sleep hygiene habits. In response, you could have introduced the topic of alcohol use treatment.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Summary - A2b</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two Summary C</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> You want to address the chief reasons for this appointment. How would you begin?</div> <div class="response"><strong>You chose:</strong> Observe Ms. Garcia for obvious signs of fatigue</div> Following up on her insomnia was important. It is also important to observe patients for physical signs related to the problem you are evaluating. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> >What else would you like to discuss with Ms. Garcia at this point?</div> <div class="response"><strong>You chose:</strong> Ask her what she needs to discuss</div> Open-ended questions are a good, patient-centered method for gathering information initially, however, at this point, there were several more focused problems to discuss: her insomnia, her efforts to improve her sleep, her drinking, and her blood test results.</div> <div class="discussion"><strong>Regarding other possible choices</strong><p>Following up on Ms. Garcia's lab results, would have revealed that she has slightly elevated liver enzymes and MCV, which suggests she is drinking more than she revealed. In doing so, she would have admitted that she had actually been consuming 3 glasses of wine before bed each night.</p><p>Asking directly about her efforts to cut back on drinking and improve her sleep hygiene habits would have led to learning that quitting drinking was harder than she thought. She was so dismayed about this, she was unable to change her sleep hygiene habits. In response, you could have introduced the topic of alcohol use treatment.</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Summary - A3c</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two Summary D</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> You want to address the chief reasons for this appointment. How would you begin?</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia to update you on her sleep hygiene and alcohol</div> Starting the appointment by asking for an update on her alcohol use and insomnia and the effects of the lifestyle changes that were planned was a good, problem/solution focused way to begin the appointment.</div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> How do you want to learn more at this point?</div> <div class="response"><strong>You chose:</strong> Discuss lab results</div> Addressing the significant lab results was also an important nest step. In particular, describing the elevated liver enzymes and increased MCV was important as these are markers for chronic excessive intake of alcohol. This led to an important discussion about her alcohol use being greater than she admitted in the first appointment.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Asking "why" she didn't stop drinking would have resulted in a defensive response. When she is asked to consider alternative treatments for her insomnia, she is very fixated on getting a prescription for a sleeping aid. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Summary - B1d</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two Summary E</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> You want to address the chief reasons for this appointment. How would you begin?</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia to update you on her sleep hygiene and alcohol</div> Starting the appointment by asking for an update on her alcohol use and insomnia and the effects of the lifestyle changes that were planned was a good, problem/solution focused way to begin the appointment.</div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> How do you want to learn more at this point?</div> <div class="response"><strong>You chose:</strong> Talk about alternative treatments for insomnia</div> This response does address her chief concern of insomnia, but ignores her revelation that it is difficult for her to quit drinking and that she hasn't changed her lifestyle to reduce stress or improve sleep hygiene. Non-pharmacological treatments are generally more effective, less expensive, and have fewer side effects than sleep medications. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Her high liver enzymes and elevated MCV are important to discuss because they are signs that she drinks more than she reported and that her drinking is harming her physically. She would have admitted that she had actually been consuming 3 glasses of wine before bed each night.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Summary - B2e</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two Summary F</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> You want to address the chief reasons for this appointment. How would you begin?</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia to update you on her sleep hygiene and alcohol</div> Starting the appointment by asking for an update on her alcohol use and insomnia and the effects of the lifestyle changes that were planned was a good, problem/solution focused way to begin the appointment.</div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> How do you want to learn more at this point?</div> <div class="response"><strong>You chose:</strong> Ask why she was unable to stop drinking</div> Helping patients get insight into their substance use is important, however, asking "why" can raise defensiveness, as it did in this case. Using "how" or "what" questions, such as, "What made quitting difficult?" often is better for developing insight and maintaining rapport. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Discussing Ms. Garcia's lab results, would have informed her that she has slightly elevated liver enzymes and MCV, which suggests she is drinking more than she revealed. She would have admitted that she had actually been consuming 3 glasses of wine before bed each night.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Summary - B3f</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two Summary G</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> You want to address the chief reasons for this appointment. How would you begin?</div> <div class="response"><strong>You chose:</strong> Talk about the lab results</div> It was important to address the lab test results. In particular, describing the elevated liver enzymes and increased MCV was important as these are markers for chronic excessive intake of alcohol. As a result, you learned that Ms. Garcia drinks more than she had admitted at her first appointment, as much as 21 glasses of wine per week. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> How do you want to further address the main reasons for this appointment?</div> <div class="response"><strong>You chose:</strong> Ask her to be honest with you</div> It is important to encourage honesty. Emphasizing that it helps you help the patient if they are honest, is a patient-centered approach that avoids using guilt. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Had you asked about her insomnia and whether she quit drinking, adopted stress management, or better sleep hygiene habits, you would have learned that, even though she knew she needed to quit drinking, she was unable to do so and that she is still struggling with insomnia. She also was unable to apply the sleep hygiene behaviors that had been discussed at appointment one. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Summary - C1g</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two Summary H</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> You want to address the chief reasons for this appointment. How would you begin?</div> <div class="response"><strong>You chose:</strong> Talk about the lab results</div> It was important to address the lab test results. In particular, describing the elevated liver enzymes and increased MCV was important as these are markers for chronic excessive intake of alcohol. As a result, you learned that Ms. Garcia drinks more than she had admitted at her first appointment, as much as 21 glasses of wine per week, and she learned that her alcohol use is impacting her physical health. </div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> How do you want to further address the main reasons for this appointment?</div> <div class="response"><strong>You chose:</strong> Ask if she has quit drinking and how she is sleeping</div> It was also important to follow up on the current status of her sleep, which is her chief complaint, and the lifestyle changes she agreed to make: quitting drinking, adopting stress management activities, and improving sleep hygiene habits. As a result, you learned that she has been unable to do any of these.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Asking a vague, open-ended question at this point is not a productive approach. Asking for honesty and candor can be an effective approach when combined with an explanation that you need it in order to be able to help your patients. She does appear to be very tired and you see dark circles under her eyes. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Summary - C2h</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Appointment Two Summary I</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> You want to address the chief reasons for this appointment. How would you begin?</div> <div class="response"><strong>You chose:</strong> Talk about the lab results</div> It was important to address the lab test results. In particular, describing the elevated liver enzymes and increased MCV was important as these are markers for chronic excessive intake of alcohol. As a result, you learned that Ms. Garcia drinks more than she had admitted at her first appointment, as much as 21 glasses of wine per week. </div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> How do you want to further address the main reasons for this appointment?</div> <div class="response"><strong>You chose:</strong> Ask her what she wants to discuss</div> Open-ended questions are a good, patient-centered method for gathering information initially, however, this one is way too non-specific. At this point, there were several more focused problems to discuss: her insomnia, her efforts to improve her sleep, her excessive drinking and introducing a discussion of alcohol use treatment.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> She does appear to be very tired and you see dark circles under her eyes. She has been unable to stop drinking or apply any sleep hygiene recommendations. Asking for honesty and candor can be an effective approach when combined with an explanation that you need it in order to be able to help your patients. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Appointment Two - Summary - C3I</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Appointment Two Assessment Update</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>It is important that I get a clear understanding of your alcohol use so that I can help you. </p> </div> <div class="patient-dialogue"> <p>Okay. I understand</p> </div> <div class="provider-dialogue"> <p>Thank you. So, to clarify, you drink around 3 drinks per night, every night, which is around 21 drinks per week?</p> </div> <div class="patient-dialogue"> <p>Yes, that's about right.</p> </div> <div class="provider-dialogue"> <p>And I want to re-ask a question I asked last week: How many days in the past year would you say that you've had more than four drinks in a day?</p> </div> <div class="patient-dialogue"> <p>I'm not really sure, but probably once or twice a month.</p> </div> <div class="provider-dialogue"> <p>Okay. So that's a little higher, too. Thank you for being honest.<i>[Based on a now positive NIAAA initial screening (NIAAA, 2005), you continue to ask questions.]</i></p> </div> <div class="provider-dialogue"> <p>I'd like to get a better understanding of how much your drinking is affecting your life - just four questions called the CAGE screen (Ewing, 1984).</p> </div> <div class="patient-dialogue"> <p>I can handle four questions.</p> </div> <div class="provider-dialogue"> <p>Have you ever felt you should cut down on your drinking?</p> </div> <div class="patient-dialogue"> <p>Yes.</p> </div> <div class="provider-dialogue"> <p>Have people annoyed you by criticizing your drinking?</p> </div> <div class="patient-dialogue"> <p>Yes, I don't like it when people criticize it. You annoyed me last week when you brought it up, and your nurse, too, so yes.</p> </div> <div class="provider-dialogue"> <p>Have you ever felt bad or guilty about your drinking?</p> </div> <div class="patient-dialogue"> <p>Yes. Recently, when I couldn't quit and I thought it would be easy but it wasn't.</p> </div> <div class="provider-dialogue"> <p>Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?</p> </div> <div class="patient-dialogue"> <p>No.</p> </div> </div> <div class="note"><strong>CAGE Results:</strong> 3 positive answers</div> </div> <div class="navigation"> <div class="question">How would you interpret Ms. Garcia's results?</div> <div class="continue">[[The results are not clinically significant]]</div> <div class="continue">[[The results are clinically significant]]</div> <div class="continue">[[Ms. Garcia has alcohol use disorder]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Physical and Screening</p> <div class="chapter"><strong>Ch 7 |</strong> Appointment Two ReScreening Two</div><div class="progress chapter7"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Appointment Two Reassessment</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I'd like to also re-ask the other questions I asked last week to continue to get a clear picture.</p> </div> <div class="patient-dialogue"> <p>Okay.</p> </div> <div class="provider-dialogue"> <p><i>[You re-ask the NIAAA questions asked the previous week. She already has admitted that she continued to drink despite it contributing to her insomnia.]</i> Has your drinking ever led you to having an accident or bodily harm or trouble with the law? </p> </div> <div class="patient-dialogue"> <p>No, nothing like that.</p> </div> <div class="provider-dialogue"> <p>Relationship or work problems?</p> </div> <div class="patient-dialogue"> <p>No.</p> </div> <div class="provider-dialogue"> <p>Do you find you are drinking more to get the same effect? </p> </div> <div class="patient-dialogue"> <p>Yes. I guess it takes more wine for me to relax at night. I started off with one glass of wine before bed. That used to be enough, but now it takes me three glasses of wine to wind down.</p> </div> <div class="provider-dialogue"> <p> Have you found that you experience withdrawal when you do not drink?</p> </div> <div class="patient-dialogue"> <p>Yes, I suppose that's what happened when I tried to quit this week. I felt miserable.</p> </div> <div class="provider-dialogue"> <p>Do you spend significant time drinking?</p> </div> <div class="patient-dialogue"> <p>No.</p> </div> <div class="provider-dialogue"> <p>Do you prioritize alcohol over more important matters?</p> </div> <div class="patient-dialogue"> <p>No. I go about my day and then I relax with some wine at night.</p> </div> </div> <div class="report"><strong>Results:</strong> Three positive responses - two in response to questioning, and one was described earlier in the appointment during the interview.</div> </div> <div class="navigation"> <div class="question">Which of the following best describes Ms. Garcia's status in terms of alcohol use disorder (AUD)?</div> <div class="continue">[[At risk for AUD]]</div> <div class="continue">[[Probably has mild AUD]]</div> <div class="continue">[[Probably has moderate AUD]]</div> <div class="continue">[[Probably has severe AUD]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two ReAssessment</p> <div class="chapter"><strong>Ch 8 |</strong> Appointment Two Reassessment</div><div class="progress chapter8"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> At risk for AUD</div> <div class="container"> <div class="inner"> <div class="feedback incorrect"> <div class="question"><strong>Question 1:</strong> Which of the following best describes Ms. Garcia's status in terms of alcohol use disorder (AUD)?</div> <div class="response"><strong>You chose:</strong> At risk for AUD </div> Since Ms. Garcia experiences at least three symptoms of alcohol use disorder, she meets the criteria for mild alcohol use disorder, which is 2 to 3 criteria, not just "at risk." She reported an inability to quit drinking, increased consumption in order to achieve the desired effects, and continued drinking despite negative health effects of drinking. However, she also lied initially about her alcohol use, which is part of another criterion, so she may have moderate alcohol use disorder. A full evaluation by an addiction specialist would finalize the diagnosis.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Use Disorder Treatment]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Reassessment A</p> <div class="chapter"><strong>Ch 8 |</strong> Appointment Two Reassessment</div><div class="progress chapter8"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Probably has mild AUD</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> Which of the following best describes Ms. Garcia's status in terms of alcohol use disorder (AUD)?</div> <div class="response"><strong>You chose:</strong> Probably has mild AUD</div> Since Ms. Garcia experiences at least three symptoms of alcohol use disorder, she meets the criteria for mild alcohol use disorder, which is 2 to 3 criteria. She reported an inability to quit drinking, increased consumption in order to achieve the desired effects, and continued drinking despite negative health effects of drinking. However, she also lied initially about her alcohol use, which is part of another criterion, so she may have moderate alcohol use disorder. A full evaluation by an addiction specialist would finalize the diagnosis.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Use Disorder Treatment]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Reassessment B</p> <div class="chapter"><strong>Ch 8 |</strong> Appointment Two Reassessment</div><div class="progress chapter8"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Probably has moderate AUD</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Which of the following best describes Ms. Garcia's status in terms of alcohol use disorder (AUD)?</div> <div class="response"><strong>You chose:</strong> Probably has moderate AUD</div> Since Ms. Garcia experiences at least three symptoms of alcohol use disorder, she meets the criteria for mild alcohol use disorder, which is 2 to 3 criteria. She reported an inability to quit drinking, increased consumption in order to achieve the desired effects, and continued drinking despite negative health effects of drinking. However, she also lied initially about her alcohol use, which is part of another criterion, so she may have moderate alcohol use disorder. A full evaluation by an addiction specialist would finalize the diagnosis.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Use Disorder Treatment]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Reassessment C</p> <div class="chapter"><strong>Ch 8 |</strong> Appointment Two Reassessment</div><div class="progress chapter8"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> The results are not clinically significant</div> <div class="container"> <div class="inner"> <div class="note"><p>Incorrect. She had 3 of 4 positive answers on the CAGE screening, which is clinically significant.</p></div></div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Physical and Screening - Discussion - A</p> <div class="chapter"><strong>Ch 7 |</strong> Appointment Two ReScreening Two</div><div class="progress chapter7"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> The results are clinically significant</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Your answers and your lab tests give me concern. Your drinking is very likely affecting your sleep and the lab tests showed it is already affecting other aspects of your health as well. I think we really need to take your drinking seriously.</p> </div> <div class="patient-dialogue"> <p> It was harder than I thought it would be to cut back. Maybe that was a warning sign.</p> </div> <div class="provider-dialogue"> <p> It is very important and I am glad you brought it up. Fortunately, there are treatments we can talk about that can help make it easier.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Alcohol Screening Update - Discussion - A</p><div class="chapter"><strong>Ch 7 |</strong>Appointment Two Alcohol Screening Update</div><div class="progress chapter7"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ms. Garcia has alcohol use disorder</div> <div class="container"> <div class="inner"> <div class="note"><p>Incorrect. Her results on the screening tool, the difficulty she had reducing alcohol on her own, and her greater use of alcohol than she originally ommitted are all signs she may have alcohol use disorder. However, this needs to be confirmed through a complete assessment and considering the criteria for this disorder.</p></div></div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Assessment Update C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Physical and Screening - Discussion - C</p> <div class="chapter"><strong>Ch 7 |</strong> Appointment Two ReScreening Two</div><div class="progress chapter7"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Appointment Two Alcohol Assessment Update Summary A</div> <div class="container"> <div class="inner"> <div class="feedback incorrect"> <div class="question"><strong>Question 1:</strong> How would you interpret Ms. Garcia's results?</div> <div class="response"><strong>You chose:</strong> The results are not clinically significant</div> Incorrect. Even 1 out of 4 positive responses has some significance and 2 out of 4 is definitely clinically significant. Ms. Garcia answered 3 out of 4 positively and also is drinking at 3 times the recommended limits.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> The new results in response to the NIAAA screening, results of the CAGE screening, the plus the interview are clinically significant and suggestive of alcohol use disorder. However, they are not sufficient to diagnose Ms. Garcia with alcohol use disorder. A diagnosis of alcohol use disorder is based on a list of specific criteria listed in the DSM 5. Each criterion would need to be explored before making this diagnosis. Often, a patient in primary care is referred for treatment, for example to an addiction specialist, and they make the final diagnosis.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Reassessment]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Physical and Screening - Summary - A1</p> <div class="chapter"><strong>Ch 7 |</strong> Appointment Two ReScreening Two</div><div class="progress chapter7"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Appointment Two Alcohol Assessment Update B</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How would you interpret Ms. Garcia's results?</div> <div class="response"><strong>You chose:</strong> The results are clinically significant</div> Correct. The new results in response to the NIAAA screening, results of the CAGE screening, the plus the interview are clinically significant and suggestive of alcohol use disorder. However, they are not sufficient to diagnose Ms. Garcia with alcohol use disorder. A diagnosis of alcohol use disorder is based on a list of specific criteria listed in the DSM 5. Each criterion would need to be explored before making this diagnosis. Often, a patient in primary care is referred for treatment, for example to an addiction specialist, and they make the final diagnosis.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> The new results in response to the NIAAA screening, results of the CAGE screening, the plus the interview are clinically significant and suggestive of alcohol use disorder. However, they are not sufficient to diagnose Ms. Garcia with alcohol use disorder. A diagnosis of alcohol use disorder is based on a list of specific criteria listed in the DSM 5. Each criterion would need to be explored before making this diagnosis. Often, a patient in primary care is referred for treatment, for example to an addiction specialist, and they make the final diagnosis.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Reassessment]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two ReScreening - Summary - B1</p> <div class="chapter"><strong>Ch 7 |</strong> Appointment Two ReScreening Two</div><div class="progress chapter7"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Appointment Two Alcohol Assessment Update C</div> <div class="container"> <div class="inner"> <div class="feedback incorrect"> <div class="question"><strong>Question 1:</strong> How would you interpret Ms. Garcia's results?</div> <div class="response"><strong>You chose:</strong> Ms. Garcia has alcohol use disorder</div> The new results in response to the NIAAA screening, results of the CAGE screening, the plus the interview are clinically significant and suggestive of alcohol use disorder. However, they are not sufficient to diagnose Ms. Garcia with alcohol use disorder. A diagnosis of alcohol use disorder is based on a list of specific criteria listed in the DSM 5. Each criterion would need to be explored before making this diagnosis. Often, a patient in primary care is referred for treatment, for example to an addiction specialist, and they make the final diagnosis.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> The new results in response to the NIAAA screening, results of the CAGE screening, the plus the interview are clinically significant and suggestive of alcohol use disorder. However, they are not sufficient to diagnose Ms. Garcia with alcohol use disorder. A diagnosis of alcohol use disorder is based on a list of specific criteria listed in the DSM 5. Each criterion would need to be explored before making this diagnosis. Often, a patient in primary care is referred for treatment, for example to an addiction specialist, and they make the final diagnosis.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Reassessment]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Physical and Screening - Summary - C1</p> <div class="chapter"><strong>Ch 7 |</strong> Appointment Two ReScreening Two</div><div class="progress chapter7"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Has severe AUD</div> <div class="container"> <div class="inner"> <div class="feedback incorrect"> <div class="question"><strong>Question 1:</strong> Which of the following best describes Ms. Garcia's status in terms of alcohol use disorder (AUD)?</div> <div class="response"><strong>You chose:</strong> Probably has severe AUD</div> Since Ms. Garcia experiences at least three symptoms of alcohol use disorder, she meets the criteria for mild alcohol use disorder, which is 2 to 3 criteria, not severe alcohol use disorder, which is 6 or more criteria. She reported an inability to quit drinking, increased consumption in order to achieve the desired effects, and continued drinking despite negative health effects of drinking. However, she also lied initially about her alcohol use, which is part of another criterion, so she may have moderate alcohol use disorder. A full evaluation by an addiction specialist would finalize the diagnosis.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Alcohol Use Disorder Treatment]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two Reassessment D</p> <div class="chapter"><strong>Ch 8 |</strong> Appointment Two Reassessment</div><div class="progress chapter8"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Appointment Two Alcohol Use Disorder Treatment</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>As we've been discussing, your alcohol use is significant and is probably a major contributor to your sleep problems. All the information put together suggests you have at least mild alcohol use disorder. I strongly recommend treatment. I'd like to talk with you about possible treatment options, if I may.</p> </div> <div class="patient-dialogue"> <p>I understand you feel like you have to focus on my alcohol use disorder, but I really just want something so I can sleep through the night since the alcohol helps me get to sleep.</p> </div> <div class="provider-dialogue"> <p>It sounds like you are motivated to improve your sleep, but as I have discussed before, the first step to treating your insomnia is to quit drinking. The fact that you were unable to cut back your alcohol use indicates this is your top priority health issue, plus would likely solve the secondary issue of your nsomnia.</p> </div> <div class="patient-dialogue"> <p>Maybe I just didn't try hard enough to cut back on my drinking. I'm not an alcoholic, it just ended up being harder than I thought to give up my wine. </p> </div> <div class="provider-dialogue"> <p>I understand this is hard to hear, but you are not alone in your struggles. That is why we need to come up with a plan to help you quit drinking.</p> </div> </div> </div> <div class="navigation"> <div class="question">How would you continue the conversation with Ms. Garcia?</div> <div class="continue">[[Ask Ms Garcia about her prior attempt to stop drinking]]</div> <div class="continue">[[Refer Ms Garcia to a specialist in addictions]]</div> <div class="continue">[[Recommend melatonin to break her insomnia and drinking cycle]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask Ms. Garcia about her prior attempt to stop drinking</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>At the end of our last appointment, you agreed to quit drinking. What strategies or did you use to go about quitting?</p> </div> <div class="patient-dialogue"> <p>Honestly, I didn't really try to quit drinking. I thought about quitting, but I ended up drinking anyway. Quitting just felt too hard and the thought of not sleeping at all was unbearable.</p> </div> </div> </div> <div class="navigation"> <div class="question">How would you respond to Ms. Garcia?</div> <div class="continue">[[Offer a referral to a sleep specialist]]</div> <div class="continue">[[Offer a referral to an addiction specialist]]</div> <div class="continue">[[Tell her about using the web to find a local AA chapter]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Question - A</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Refer Ms. Garcia to a specialist in addictions</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I think the best course of treatment would be for you to see an addiction specialist. Does that sound like something you would consider?</p> </div> <div class="patient-dialogue"> <p>How is a specialist going to help me?</p> </div> <div class="provider-dialogue"> <p>A specialist can work with you to find strategies that will help you quit drinking. Also, if there are underlying emotional issues contributing to your insomnia and drinking, a specialist can help you work through those.</p> </div> </div> </div> <div class="navigation"> <div class="question">Of the following, what is the most effective next treatment strategy?</div> <div class="continue">[[Tell her to ask her friends if they know anyone who treats addictions]]</div> <div class="continue">[[Offer to call the addiction specialist]]</div> <div class="continue">[[Tell her to contact someone at AA for a referral]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Question - B</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Recommend melatonin to break her insomnia and drinking cycle</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Since insomnia seems to be your trigger for alcohol intake, I think taking melatonin before bed will break the insomnia/drinking cycle you are experiencing.</p> </div> <div class="patient-dialogue"> <p>Melatonin? I've never heard of that.</p> </div> <div class="provider-dialogue"> <p>Melatonin is an over-the-counter supplement that has been shown to help with insomnia. You can purchase it at your local pharmacy or vitamin store. Instead of drinking wine at night, take the melatonin. It should help you sleep.</p> </div> </div> </div> <div class="navigation"> <div class="question">What additional recommendation would you give Ms. Garcia to help her quit drinking?</div> <div class="continue">[[Seek out an AA meeting]]</div> <div class="continue">[[See an addiction specialist]]</div> <div class="continue">[[Ask her friends to keep her accountable]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Question - C</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Offer a referral to a sleep specialist</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>The fear of not being able to sleep at night seems to be preventing you from quitting drinking. I can refer you to a sleep specialist. If a sleep specialist can help resolve your insomnia, you may be able to quit drinking on your own.</p> </div> <div class="patient-dialogue"> <p>I'll see the sleep specialist.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[AUD Treatment Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Discussion - A1</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Offer a referral to an addiction specialist</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I can refer you to an addiction specialist. Someone who specializes in addictions can help you work through your fears and inability to quit drinking.</p> </div> <div class="patient-dialogue"> <p>I'm not sure about that, because I'm not an alcoholic, just drinking a little more than I should. But I'll consider it.</p> </div> <div class="provider-dialogue"> <p>Please do give it some thought. I really think an addiction specialist can help you cut back and prevent you from escalating your use to the point of alcohol dependence you associate with being an "alcoholic.".</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[AUD Treatment Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Discussion - A2</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her about using the web to find a local AA chapter</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>You can always go online and locate a local chapter of AA. I am sure they have great resources for treatment.</p> </div> <div class="patient-dialogue"> <p>Do you really think that could help? I'm just having a hard time seeing myself as someone who should be a part of AA, but I guess that might be an option.</p> </div> <div class="provider-dialogue"> <p>Being around others who have trouble cutting back on drinking regardless of the severity of their particular problem and getting their support should have some benefit. I am sure you can find a meeting that fits your schedule.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[AUD Treatment Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Discussion - A3</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her to ask her friends if they know anyone who treats addictions</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>You could ask your friends if they know any addiction specialists. Your friends know you better than I do. I think they will be able to recommend someone you would be comfortable working with.</p> </div> <div class="patient-dialogue"> <p>That means I'd have to tell my friends about my alcohol use disorder.</p> </div> <div class="provider-dialogue"> <p>I am sure your friends will be concerned and want to help. Your friends could even be part of your support network.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[AUD Treatment Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Discussion - B2</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Seek out an AA meeting</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>In addition to taking the melatonin, I recommend attending an AA meeting. AA can provide you with a community of people who can help you quit drinking.</p> </div> <div class="patient-dialogue"> <p>I hope the melatonin will be enough. I'm not sure I really want to go to AA meetings.</p> </div> <div class="provider-dialogue"> <p>Even if the melatonin helps, it might be nice to have a community of people to help you stay sober.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[AUD Treatment Summary G]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Discussion - C1</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> See an addiction specialist</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>In addition to taking the melatonin, I recommend seeing an addiction specialist. A specialist can provide you with additional strategies to quit drinking.</p> </div> <div class="patient-dialogue"> <p>I don't think I need a specialist. The melatonin should be enough. I wish you would have told me to take melatonin at our last appointment.</p> </div> <div class="provider-dialogue"> <p>The best choice for treating your insomnia is to stop drinking, but since that has proven to be difficult and will take some time, the melatonin might help you get some sleep while the resources I've recommended help you cut out the alcohol. Please remain open to the idea of a specialist.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[AUD Treatment Summary H]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Discussion - C2</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her friends to keep her accountable</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Social support can really help someone quit drinking. I recommend that you tell your friends about your alcohol use disorder and ask them to keep you accountable to sobriety. Your friends could call and check in with you to make sure that you are not drinking and you could call them when you are tempted to drink.</p> </div> <div class="patient-dialogue"> <p>I'd rather not tell them that I have alcohol use disorder.</p> </div> <div class="provider-dialogue"> <p>You do not have to tell them you have alcohol use disorder. You can just tell them you are trying to quit drinking and you would like their support.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[AUD Treatment Summary I]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Discussion - C3</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Offer to call the addiction specialist</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I could call the addiction specialist right now and make sure you get into treatment. If you are willing to sign this consent form, I will write and fax a letter of referral on your behalf to the specialist. Signing the consent form will also let me be in contact with the specialist throughout your treatment.</p> </div> <div class="patient-dialogue"> <p>Okay. Where do I sign?</p> </div> <div class="provider-dialogue"> <p>Thank you. I will send the letter of referral right now and have the front desk set up your appointment. Being in contact with your addiction specialist will help us give you the best possible treatment.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[AUD Treatment Summary D]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Discussion - B1</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her to contact someone at AA for a referral</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I think you should contact someone at AA. I am sure they have a list of people who treat alcohol use disorders.</p> </div> <div class="patient-dialogue"> <p>Thanks for the suggestion.</p> </div> <div class="provider-dialogue"> <p>I hope you will follow through with it.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[AUD Treatment Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Discussion - B3</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> AUD Treatment Summary A</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia about her prior attempt to stop drinking</div> Getting an understanding of what happened with her quit attempt is an important starting point in her substance use counseling. Asking this question is especially important if you are the one that will be providing this treatment rather than an addiction specialist or substance use counselor. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> How would you respond to Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Offer a referral to a sleep specialist</div> A sleep specialist may need to be consulted regarding her insomnia, especially if alcohol treatment is not effective. Both conditions need to be a focus of Ms. Garcia's treatment at this point since the conditions reinforce each other.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Ms. Garcia has alcohol use disorder and has been unable to quit drinking on her own. This indicates that she needs to be seen by an addiction specialist. If you obtained her consent to refer her to an addiction specialist and to be in contact with her specialist, she would be more likely to follow through. Provider assistance in locating and coordinating care for patients with alcohol use disorders has been shown to increase treatment retention rates (McKay & Hiller-Sturmhofel, 2011).</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Followup Conversation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Summary - A1a</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> AUD Treatment Summary B</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia about her prior attempt to stop drinking</div> Getting an understanding of what happened with her quit attempt is an important starting point in her substance use counseling. Asking this question is especially important if you are the one that will be providing this treatment rather than an addiction specialist or substance use counselor. </div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> How would you respond to Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Offer a referral to an addiction specialist</div> <p>Ms. Garcia is still in denial about the severity of her problem and associates addiction counseling with being the stereotypical "alcoholic." Emphasizing how an addictions counselor can help even mild and moderate alcohol abuse can make her less resistant to the referral. </p> <p>If you are not going to be providing her addiction treatment yourself, the best course of action is to obtain her consent and directly refer Ms. Garcia to an addiction specialist. This treatment is warranted given her probable alcohol use disorder diagnosis. Direct referral increases her chances of seeing the specialist and allows you to be in contact with her specialist. Provider assistance in locating and coordinating care for patients with alcohol use disorders has been shown to increase treatment retention rates (McKay & Hiller-Sturmhofel, 2011). This is known as a "warm referral."</p> </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Melatonin has been shown to be effective in the treatment of primary sleep disorders (Ferracioli-Oda et al., 2013), but may not help with insomnia secondary to alcohol use disorder. A sleep specialist may need to be consulted regarding her insomnia, especially if alcohol treatment is not effective. Both conditions need to be a focus of Ms. Garcia's treatment at this point since the conditions reinforce each other.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Followup Conversation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Summary - A2b</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> AUD Treatment Summary C</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia about her prior attempt to stop drinking</div> Getting an understanding of what happened with her quit attempt is an important starting point in her substance use counseling. Asking this question is especially important if you are the one that will be providing this treatment rather than an addicion specialist or substance use counselor. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> How would you respond to Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Tell her about using the web to find a local AA chapter</div> AA may help Ms. Garcia. However, a loose recommendation is unlikely to motivate her to attend. Helping her find a specific meeting to attend, including the days and times, would be more effective.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> If you are not going to be providing her addiction treatment yourself, the best course of action would have been to have obtained her consent and directly referred Ms. Garcia to an addiction specialist. Treatment is warranted given her diagnosis of probable alcohol use disorder. Direct referral would have increased her chances of seeing the specialist and would have allowed you to be in contact with her specialist. Provider assistance in locating and coordinating care for patients with alcohol use disorders has been shown to increase treatment retention rates (McKay & Hiller-Sturmhofel, 2011). This is known as a "warm referral."</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Followup Conversation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Summary - A3c</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> AUD Treatment Summary D</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Refer Ms. Garcia to a specialist in addictions</div> Given her probable diagnosis of at least mild alcohol use disorder, a referral to an addiction specialist is appropriate.</div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Of the following, what is the most effective next treatment strategy?</div> <div class="response"><strong>You chose:</strong> Offer to call the addiction specialist</div> Making the call to an addiction specialist is an effective way of making increasing the chances that Ms. Garcia gets the treatment she needs. Provider assistance in locating and coordinating care for patients with alcohol use disorders has been shown to increase treatment retention rates (McKay & Hiller-Sturmhofel, 2011). This is called a "warm referral." It is also important that you remain in contact with her specialist to monitor her case.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Melatonin has been shown to be effective in the treatment of primary sleep disorders (Ferracioli-Oda et al., 2013), but may not help with insomnia secondary to alcohol use disorder. Getting an understanding of what happened with her quit attempt is an important starting point in her substance use counseling. Asking this question is especially important if you are the one that will be providing this treatment rather than an addicion specialist or substance use counselor. Group supports, such as AA, can be an effective source of the social support component of treatment. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Followup Conversation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Summary - B1d</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> AUD Treatment Summary E</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Refer Ms. Garcia to a specialist in addictions</div> Given her probable diagnosis of at least mild alcohol use disorder, a referral to an addiction specialist is appropriate. </div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> Of the following, what is the most effective next treatment strategy?</div> <div class="response"><strong>You chose:</strong> Tell her to ask her friends if they know anyone who treats addictions</div> While she needs to be referred to an addiction specialist, telling her to ask her friends was not an effective way of ensuring that she gets the care she needs. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> A better course of action would have been for you to have obtained her consent to refer her to an addiction specialist and to be in contact with her specialist yourself. This is called a warm referral Provider assistance in locating and coordinating care for patients with alcohol use disorders has been shown to increase treatment retention rates (McKay & Hiller-Sturmhofel, 2011).</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Followup Conversation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Summary - B2e</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> AUD Treatment Summary F</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Refer Ms. Garcia to a specialist in addictions</div> Given her probable diagnosis of at least mild alcohol use disorder, a referral to an addiction specialist is appropriate. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Of the following, what is the most effective next treatment strategy?</div> <div class="response"><strong>You chose:</strong> Tell her to contact someone at AA for a referral</div> Advising her to contact an AA member was not the most effective way of ensuring that she receives the care she needs. But this can be a secondary source of support and is effective for many people. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> A better course of primary treatment would have been for you to have obtained her consent to refer her to an addiction specialist and to be in contact with her specialist. Provider assistance in locating and coordinating care for patients with alcohol use disorders has been shown to increase treatment retention rates (McKay & Hiller-Sturmhofel, 2011). This is called a "warm referral."</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Followup Conversation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Summary - B3f</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> AUD Treatment Summary G</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Recommend melatonin to break her insomnia and drinking cycle</div> Melatonin has been shown to be effective in the treatment of primary sleep disorders (Ferracioli-Oda et al., 2013). However, Ms. Garcia's insomnia appears to be secondary to her alcohol use disorder. If so, this may not be an appropriate treatment recommendation.</div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What additional recommendation would you give Ms. Garcia to help her quit drinking?</div> <div class="response"><strong>You chose:</strong> Seek out an AA meeting</div> AA may help Ms. Garcia. However, a loose recommendation is unlikely to motivate her to attend. Helping her find a specific meeting to attend, including the days and times, would be more effective.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> The best course of action would have been to have obtained her consent and directly referred Ms. Garcia to an addiction specialist. This would have increased her chances of seeing the specialist and would have allowed you to be in contact with her specialist. Provider assistance in locating and coordinating care for patients with alcohol use disorders has been shown to increase treatment retention rates (McKay & Hiller-Sturmhofel, 2011). This is known as a "warm referral."</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Followup Conversation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Summary - C1g</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> AUD Treatment Summary H</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Recommend melatonin to break her insomnia and drinking cycle</div> Melatonin has been shown to be effective in the treatment of primary sleep disorders (Ferracioli-Oda et al., 2013). However, Ms. Garcia's insomnia appears to be secondary to her alcohol use disorder. If so, this may not be an appropriate treatment recommendation.</div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What additional recommendation would you give Ms. Garcia to help her quit drinking?</div> <div class="response"><strong>You chose:</strong> See an addiction specialist</div> Given her probable diagnosis of at least mild alcohol use disorder, a referral to an addiction specialist is appropriate.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> The best course of action would have been to directly refer Ms. Garcia to an addiction specialist, work through her hesitations and obtain her consent for the referral. Provider assistance in locating and coordinating care for patients with alcohol use disorders has been shown to increase treatment retention rates (McKay & Hiller-Sturmhofel, 2011). This is called a "warm referral."</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Followup Conversation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Summary - C2h</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> AUD Treatment Summary I</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Recommend melatonin to break her insomnia and drinking cycle</div> Melatonin has been shown to be effective in the treatment of primary sleep disorders (Ferracioli-Oda et al., 2013). However, Ms. Garcia's insomnia appears to be secondary to her alcohol use disorder. If so, this may not be an appropriate treatment recommendation.</div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What additional recommendation would you give Ms. Garcia to help her quit drinking?</div> <div class="response"><strong>You chose:</strong> Ask her friends to keep her accountable</div> Support from friends can be very helpful in maintaining sobriety, as a secondary treatment. Ms. Garcia needs more specialized treatment as her primary treatment, however.</div> <div class="discussion"><strong>Regarding other treatments:</strong> The best course of action would have been to have obtained her consent and directly referred Ms. Garcia to an addiction specialist. Provider assistance in locating and coordinating care for patients with alcohol use disorders has been shown to increase treatment retention rates (McKay & Hiller-Sturmhofel, 2011). This is known as a "warm referral."</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Appointment Two Followup Conversation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Summary - C3I</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Appointment Two Follow Up Conversation</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I will send you the letter of referral today and ask that they see you within one week. It is important that you start treatment soon in order to help with your insomnia and your alcohol use disorder.</p> </div> <div class="patient-dialogue"> <p>Sounds good.</p> </div> <div class="provider-dialogue"> <p>We'll also continue to work on improving your sleep in other ways, so please make an appointment with my office for 2 weeks on your way out.</p> </div> <div class="patient-dialogue"> <p>Thanks.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Ms Garcia Appointment Two Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two AUD Treatment - Followup</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div> </div></div>

<div class="yourchoice"><strong>You chose:</strong> Ms. Garcia Appointment Two Summary</div> <div class="container"> <div class="inner"> <div class="summary"> <p><strong>Patient Info/CC/HPI (Subjective):</strong> Ms. Garcia was unable to abstain from alcohol, adopt stress management activities, or change sleep hygiene habits as recommended at her first appointment and continues to suffer from insomnia.</p><p><strong>P.E./Labs/Screenings (Objective):</strong> Significant blood test results from previous week, elevated MCV and AST, were discussed. Revised alcohol use assessment confirmed excessive alcohol use, beyond weekly limits (3x) and limits for single occasions at least 2X/month.</p><p><strong>Working Diagnoses:</strong> Mild alcohol use disorder; insomnia secondary to excessive alcohol use and stress</p><p><strong>Brief interventions/Treatment (Plan):</strong> Referred to addiction specialist for treatment. Referral letter informed addiction specialist of Ms. Garcia's<ul><li>History of being dishonest about her alcohol use</li><li>NIAAA screening results - 3 positive responses - Significant for probable alcohol use disorder, CAGE results: Clinically significant - 3 positive responses out of 4</li><li>Blood test results (Mildly elevated liver enzymes and MCV) which suggest heavy alcohol consumption</li><li>History of insomnia</li><li>Physical exam results</li><li>Past attempts to quit drinking and improve her sleep</li></ul> Followup plan was for Ms. Garcia to return to the office in 2 weeks to continue evaluation and other treatment of her sleep problem.</p><p>Unfortunately, she never showed for her next appointment and did not respond to a followup phone call.</p></div></div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Ms Garcia Event Three]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Appointment Two Summary</p> <div class="chapter"><strong>Ch 9 |</strong> Appointment Two AUD Treatment</div><div class="progress chapter9"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ms. Garcia Event Three</div> <div class="container"> <div class="inner"> <div class="summary"><p><strong> St. Luke's Hospital Emergency Department Patient Report </strong></p><p><strong>Patient Name:</strong> Maria Garcia</p><p><strong>Chief Complaint:</strong> Temporarily lost consciousness and was unresponsive.</p><p><strong>History of Present Illness:</strong> Found unconscious in her home by a friend who called EMS. Ms. Garcia regained consciousness before EMS arrived, but was mildly disoriented with decreased alertness. Ms. Garcia agreed to be transported by ambulance to the ED at St. Luke's Hospital. EMS noted the scent of alcohol on her breath.</p><p><strong>Medications:</strong> No medications administered.</p><p><strong>Labs:</strong> Full panel of labs including toxicology drawn STAT. Results are pending.</p></div></div> <div class="navigation"> <div class="question">Now taking the role of her ED physician, how would you start to evaluate Ms. Garcia?</div> <div class="continue">[[Ask Ms Garcia if she took something besides alcohol]]</div> <div class="continue">[[Ask the friend about the incident]]</div> <div class="continue">[[Conduct a standard patient orientation exam]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms Garcia Event Three</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask Ms. Garcia if she took something besides alcohol</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Ms. Garcia, have you had anything besides alcohol?</p> </div> <div class="patient-dialogue"> <p>I just had too much to drink; a whole bottle of wine, I think. Really, I'm fine. I just got a little faint and my friend panicked.<i>[Pauses for a moment, then slowly recalls something.]</i> I may have taken an alprazolam earlier, but just one.</p> </div> </div> </div> <div class="navigation"> <div class="question"> Of the following, what should come next in evaluating Ms. Garcia?</div> <div class="continue">[[Interview the friend about the incident]]</div> <div class="continue">[[Perform a standard patient orientation exam on Ms Garcia]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Question - A</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask the friend about the incident</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Can you please tell me what happened?</p> </div> <div class="friend-dialogue"> <p>We made plans to see a show this evening and I said I'd do the driving. I went to her house to pick her up. When she didn't answer the door, I got nervous. I have a key to her house, so I let myself in. That's when I found her only semi-conscious. I wasn't sure if she was just drunk or something worse. I didn't know what to do so I just called 911. I hope that was okay.</p> </div> <div class="provider-dialogue"> <p>Ms. Garcia is lucky that you came over. You did the right thing by calling the ambulance.</p> </div> <div class="friend-dialogue"> <p>Is she going to be okay?</p> </div> <div class="provider-dialogue"> <p>We need to take a look at her now. We will do our best to take care of her.</p> </div> </div> </div> <div class="navigation"> <div class="question"> What further information would you elicit about Ms. Garcia?</div> <div class="continue">[[Ask Ms Garcia she took anything besides alcohol]]</div> <div class="continue">[[Do a standard patient orientation exam on Ms Garcia]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Question - B</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Interview the friend about the incident</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Can you please tell me what happened?</p> </div> <div class="friend-dialogue"> <p>We made plans to see a show this evening and I said I'd do the driving. I went to her house pick her up. When she didn't answer the door, I got nervous. I have a key to her house, so I let myself in. That's when I found her unconscious. I didn't know what to do, so I just called 911.</p> </div> <div class="provider-dialogue"> <p>Ms. Garcia is lucky that you came over. You did the right thing by calling the ambulance.</p> </div> <div class="friend-dialogue"> <p>Is she going to be okay?</p> </div> <div class="provider-dialogue"> <p>We need to evaluate her first; we'll do our best to take care of her.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED History Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Discussion - A2</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Perform a standard patient orientation exam on Ms. Garcia</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Ms. Garcia, do you know where you are?</p> </div> <div class="patient-dialogue"> <p>I think I'm in the emergency department?</p> </div> <div class="provider-dialogue"> <p>Good, do you know which hospital?</p> </div> <div class="patient-dialogue"> <p>Sure, St. Luke's.</p> </div> <div class="provider-dialogue"> <p>Okay, and do you know your full name? </p> </div> <div class="patient-dialogue"> <p>My name is Maria Garcia.</p> </div> <div class="provider-dialogue"> <p>What day of the week is it?</p> </div> <div class="patient-dialogue"> <p>Saturday.</p> </div> <div class="provider-dialogue"> <p>Can you tell me how many fingers I am holding up?<i> [Now holding up three fingers.]</i></p> </div> <div class="patient-dialogue"> <p>Three.</p> </div> <div class="provider-dialogue"> <p>Good.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED History Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Discussion - A3</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Conduct a standard patient orientation exam</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Hello, Ms. Garcia, I am glad to see that you are awake. Do you know where you are?</p> </div> <div class="patient-dialogue"> <p>Looks I'm in the emergency department.</p> </div> <div class="provider-dialogue"> <p>Good, do you know which hospital?</p> </div> <div class="patient-dialogue"> <p>St. Luke's</p> </div> <div class="provider-dialogue"> <p>Okay, and do you know your full name?</p> </div> <div class="patient-dialogue"> <p>My name is Maria Garcia.</p> </div> <div class="provider-dialogue"> <p>What day of the week is it?</p> </div> <div class="patient-dialogue"> <p>Saturday.</p> </div> <div class="provider-dialogue"> <p>Can you tell me how many fingers I am holding up? <i>[You hold up three fingers.]</i></p> </div> <div class="patient-dialogue"> <p>Three.</p> </div> <div class="provider-dialogue"> <p>Good, and do you remember what happened?</p> </div> <div class="patient-dialogue"> <p>I'm not too sure. I may have had too much wine and sort of passed out. When I my friend came, I woke up. She said she had called an ambulance.</p> </div> </div> </div> <div class="navigation"> <div class="question">How would you further question Ms. Garcia?</div> <div class="continue">[[Ask Ms Garcia if she took any medications or drugs besides alcohol]]</div> <div class="continue">[[Ask the friend what happened]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Question - C</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask Ms. Garcia if she took any medications or drugs besides alcohol</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Ms. Garcia, have you had anything besides alcohol?</p> </div> <div class="patient-dialogue"> <p>I just had too much to drink, a whole bottle of wine, I think. Really, I'm fine. I just got a little faint and my friend panicked.<i>[Pauses for a moment, then slowly recalls something.]</i>I may have taken an alprazolam earlier, but just one.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED History Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Discussion - C1</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask the friend what happened</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Can you please tell me what happened?</p> </div> <div class="friend-dialogue"> <p>We made plans to see a show this evening and I said I'd do the driving. I went to her house to pick her up. When she didn't answer the door, I got nervous. I have a key to her house, so I let myself in. That's when I found her only semi-conscious. I wasn't sure if she was just drunk or something worse. I didn't know what to do so I just called 911. I hope that was okay.</p> </div> <div class="provider-dialogue"> <p>Ms. Garcia is lucky that you came over. You did the right thing by calling the ambulance.</p> </div> <div class="friend-dialogue"> <p>Is she going to be okay?</p> </div> <div class="provider-dialogue"> <p>We need to take a look at her now. We will do our best to take care of her.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED History Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Discussion - C2</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask Ms. Garcia if she took anything besides alcohol</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Ms. Garcia, have you had anything besides alcohol?</p> </div> <div class="patient-dialogue"> <p>I just had too much to drink, a whole bottle of wine, I think. Really, I'm fine. I just got a little faint and my friend panicked.<i>[Pauses for a moment, then slowly recalls something.]</i> I may have taken an alprazolam earlier, but just one.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED History Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Discussion - B2</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Do a standard patient orientation exam on Ms. Garcia</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Hello, Ms. Garcia, I am glad to see that you are awake. Do you know where you are?</p> </div> <div class="patient-dialogue"> <p>I think I'm in the emergency department?</p> </div> <div class="provider-dialogue"> <p>Good, do you know which hospital?</p> </div> <div class="patient-dialogue"> <p>St Luke's</p> </div> <div class="provider-dialogue"> <p>Okay, and do you know your full name?</p> </div> <div class="patient-dialogue"> <p>My name is Maria Garcia.</p> </div> <div class="provider-dialogue"> <p>What day of the week is it?</p> </div> <div class="patient-dialogue"> <p>Saturday.</p> </div> <div class="provider-dialogue"> <p>Can you tell me how many fingers I am holding up?<i>[You hold up three fingers]</i></p> </div> <div class="patient-dialogue"> <p>Three.</p> </div> <div class="provider-dialogue"> <p>Good, and do you remember what happened?</p> </div> <div class="patient-dialogue"> <p>I had too much wine and sort of passed out. When I my friend came, I woke up. She said she had called an ambulance.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED History Summary D]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Discussion - B3</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> ED History Summary A</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Now taking the role of her ED physician, how would you start to evaluate Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia if she took something besides alcohol</div> Given her possible loss of consciousness and continued partial disorientation, it was appropriate to ask Ms. Garcia about the amount of alcohol she had and whether she took anything else. As a result you learned that she had mixed a whole bottle of wine with a benzodiazepine, which is a dangerous combination. However, it would be better to conduct the standard evaluation first to ascertain her level of consciousness and then you can get into alcohol use.</div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> Of the following, what should come next in evaluating Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Interview the friend about the incident</div> It is appropriate to obtain information from the friend, since Ms. Garcia may not be able to give a complete history. However, doing a mental status exam on Ms. Garcia immediately to rule out serious problems, would be more appropriate. </div> <div class="discussion"><strong>Regarding other possible choices:</strong><p>A standard patient orientation exam on Ms. Garcia, you would have revealed that Ms. Garcia has proper time, person, place, and object orientation, but has partial disorientation to situation (not fully sure of what happened).</p><strong> Ms. Garcia's Lab Results:</strong><p> BAC 0.1%; benzodiazepine 20 ng/mL; glucose 72 mg/dL</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED Discharge Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Summary - A1</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> ED History Summary B</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Now taking the role of her ED physician, how would you start to evaluate Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask Ms. Garcia if she took anything else besides alcohol</div> Given her possible loss of consciousness and continued partial disorientation, it was appropriate to ask Ms. Garcia about the amount of alcohol she had and whether she took anything else. As a result you learned that she had mixed a whole bottle of wine with a benzodiazepine, which is a dangerous combination. However, it would be better to conduct the standard evaluation first to ascertain her level of consciousness and then you can get into alcohol use.</div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Of the following, what should come next in evaluating Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Perform a standard patient orientation exam on Ms Garcia</div> Performing a standard patient orientation exam on Ms. Garcia is very important, however, it should be completed immediately to rule out more serious problems. Ms. Garcia has proper time, person, place, and object orientation, but has partial disorientation to situation (not fully sure of what happened).</div> <div class="discussion"><strong>Regarding other possible choices:</strong> <p>If you had talked with her friend, you would have learned that she didn't show up for a planned activity together and that she was only semi-conscious when the friend first arrived.</p><strong>Ms. Garcia's Lab Results:</strong> <p>BAC 0.1%; benzodiazepine 20 ng/mL; glucose 72 mg/dL</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED Discharge Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Summary - A2</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> ED History Summary C</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Now taking the role of her ED physician, how would you start to evaluate Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask the friend about the incident</div> It is appropriate to obtain information from the friend, since Ms. Garcia may not be able to give a complete history. However, doing a mental status exam on Ms. Garcia immediately to rule out serious problems, would be more appropriate. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What further information would you elicit about Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask Ms Garcia if she took anything besides alchol</div> Given her possible loss of consciousness and continued partial disorientation, it was appropriate to ask Ms. Garcia about the amount of alcohol she had and whether she took anything else. As a result you learned that she had mixed a whole bottle of wine with a benzodiazepine, which is a dangerous combination.</div> <div class="discussion"><strong>Regarding other possible choices:</strong><p> While an open-ended question about how you can help your patient may be appropriate for a primary care setting, it is not an appropriate approach to treating a patient who was taken to the ED after being found unconscious and unresponsive. Rather, it is important to assess her current status and ask her directly about any substances she may have taken prior to passing out, especially since the EMS noted traces of alcohol on her breath.</p><p> A standard patient orientation exam would have revealed that Ms. Garcia has proper time, person, place, and object orientation, but has partial disorientation to situation (not fully sure of what happened). Then, interviewing Ms. Garcia about substance use prior to the incident would have revealed that she consumed alcohol and alprazolam prior to passing out.</p><p><strong>Ms. Garcia's Lab Results:</strong> BAC 0.1%; benzodiazepine 20 ng/mL; glucose 72 mg/dL</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED Discharge Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Summary - B1</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose: </strong>ED History Summary D</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Now taking the role of her ED physician, how would you start to evaluate Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask the friend about the incident</div> It is appropriate to obtain information from the friend, since Ms. Garcia may not be able to give a complete history. However, doing a mental status exam on Ms. Garcia immediately to rule out serious problems, would be more appropriate. </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What further information would you elicit about Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Do a standard patient orientation exam on Ms. Garcia</div> Performing a standard patient orientation exam on Ms. Garcia was the best initial action to take. Ms. Garcia has proper time, person, place, and object orientation, but has partial disorientation to situation (not fully sure of what happened). It would have been best to perform this test immediately to rule out more serious problems. </div> <div class="discussion"><strong><p>Regarding other possible choices:</strong> Asking Ms. Garcia directly about substances she may have taken, would have revealed that she had mixed a whole bottle of wine with a benzodiazepine, which is a dangerous combination.</p><p><strong>Ms. Garcia's Lab Results:</strong> BAC 0.1%; benzodiazepine 20 ng/mL; glucose 72 mg/dL</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED Discharge Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Summary - B2</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong> You chose:</strong> ED History Summary E</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> Now taking the role of her ED physician, how would you start to evaluate Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Conduct a standard patient orientation exam</div> Performing a standard patient orientation exam on Ms. Garcia was the best initial action to take. Ms. Garcia Ms. Garcia has proper time, person, place, and object orientation, but has partial disorientation to situation (not fully sure of what happened). </div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> How would you further question Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask Ms Garcia if she took any medications or drugs besides alcohol</div> Given her possible loss of consciousness and continued partial disorientation, it was appropriate to ask Ms. Garcia about the amount of alcohol she had and whether she took anything else. As a result you learned that she had mixed a whole bottle of wine with a benzodiazepine, which is a dangerous combination. </div> <div class="discussion"><strong>Regarding other possible choices:</strong><p> If you had talked with her friend, you would have learned that she didn't show up for a planned activity together and that she was only semi-conscious when the friend first arrived.</p><p><strong>Ms. Garcia's Lab Results:</strong> BAC 0.1%; benzodiazepine 20 ng/mL; glucose 72 mg/dL</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED Discharge Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Summary - C1</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong> You chose:</strong> ED History Summary F</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> Now taking the role of her ED physician, how would you start to evaluate Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Conduct a standard patient orientation exam</div> Performing a standard patient orientation exam on Ms. Garcia was the best initial action to take. Ms. Garcia has proper time, person, place, and object orientation, but has partial disorientation to situation (not fully sure of what happened). </div> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How would you further question Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask the friend what happened.</div> It is appropriate to obtain information from the friend, if Ms. Garcia was not be able to give a complete history. As it turns out, more information was obtained by talking directly to Ms. Garcia. </div> <div class="discussion"><strong>Regarding other possible choices:</strong><p> The EMS noted traces of alcohol on her breath, so it would have been appropriate to ask Ms. Garcia about he alcohol use and any other substances she may have taken. If you had asked Ms. Garcia directly about substances she may have taken, you would have learned that she had mixed a whole bottle of wine with a benzodiazepine, which is a dangerous combination.</p><p><strong> Ms. Garcia's Lab Results:</strong> BAC 0.1%; benzodiazepine 20 ng/mL; glucose 72 mg/dL</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[ED Discharge Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Ms. Garcia Event Three - Summary - C2</p> <div class="chapter"><strong>Ch 10 |</strong> Ms Garcia Event Three</div><div class="progress chapter10"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> ED Discharge Plan</div> <div class="container"> <div class="inner"> <div class="note">Ms. Garcia was observed until she seemed fully alert and oriented and then the following was discussed:</div> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Can we talk about your alcohol consumption and the dangers of mixing it with drugs like alprazolam?</p> </div> <div class="patient-dialogue"> <p>I guess. I know you recommended an addiction specialist, but I never went. They thought it was causing my insomnia. My drinking has actually increased since then. For the past few months, I've been having four or five drinks a day. The past few weeks, I started adding alprazolam that I got from a friend, to help me sleep.</p> </div> <div class="provider-dialogue"> <p>It's very dangerous to mix alprazolam or any benzodiazepine drug. It could be so successful in helping you sleep that you never wake up. I'd like you to promise to never mix them again.</p> </div> <div class="patient-dialogue"> <p>Are you saying I could have died? Wow. I guess I really do need some help.</p> </div> </div> </div> <div class="navigation"><div class="question"> What further treatment would you recommend?</div> <div class="continue">[[Obtaining primary care appointment for treatment of substance use problem]] </div> <div class="continue">[[Referral to intensive outpatient program]] </div> <div class="continue">[[Inpatient hospitalization]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Obtaining primary care appointment for treatment of substance use problem</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I recommend calling your primary care doctor to get some treatment for your alcohol use and risky use of prescription medications.</p> </div> <div class="patient-dialogue"> <p>I feel a little uncomfortable doing that because I'm embarrassed. I didn't do anything they recommended.</p> </div> </div> </div> <div class="navigation"> <div class="question">How would you continue the conversation with Ms. Garcia?</div> <div class="continue">[[Ask her how stopping alcohol would improve her life]]</div> <div class="continue">[[Tell her this is what you need to do for your health]]</div> <div class="continue">[[Tell her many patients feel the same way]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Question - A</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Referral to intensive outpatient program</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I recommend that you get some treatment for your alcohol use and soon. I think an intensive outpatient treatment program would best meet your needs. They meet three days a week for four hours. I have heard from several patients that they make supportive connections with the other patients in the program. I think it would be good to have a circle of friends who are also in recovery. If it is okay with you, I will call the program right now and see if they have an opening.</p> </div> <div class="patient-dialogue"> <p>Wait a minute. I'm not sure if I'm ready for this.</p> </div> </div> </div> <div class="navigation"> <div class="question">What would you say to continue the conversation with Ms. Garcia?</div> <div class="continue">[[Ask her how her life would improve if she stopped using alcohol]]</div> <div class="continue">[[Tell her that her feelings are not unique]]</div> <div class="continue">[[Tell her that her health is at stake]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Question - B</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Inpatient hospitalization</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I would like to transfer you to an inpatient acute hospitalization setting. You still need to be medically monitored, so I do not feel comfortable discharging you. Once things are stable, the hospital will evaluate what level of care you need to maintain sobriety.</p> </div> <div class="patient-dialogue"> <p>That sounds extreme. I just want to go home. I'll see the addiction specialist you recommended. I don't want to stay in the hospital.</p> </div> </div> </div> <div class="navigation"> <div class="question">How would you continue the conversation?</div> <div class="continue">[[Ask her about how stopping alcohol would improve her life]]</div> <div class="continue">[[Tell her she has to do this for her health]]</div> <div class="continue">[[Tell her she is not the only one who feels this way]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Question - C</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her how stopping alcohol would improve her life</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Talk to me about how stopping alcohol would improve your life.</p> </div> <div class="patient-dialogue"> <p>I guess I'd be less likely to pass out and end up in the ED. Also, I don't like feeling as though I need alcohol to get through the day. I'd like to enjoy my life and not always be thinking about when I'm going to have my next glass of wine. And then there's the insomnia. I'd love to sleep through the night for once.</p> </div> <div class="provider-dialogue"> <p>It sounds like you could really benefit from seeking treatment. Be sure to call my office to arrange an appointment tomorrow.</p> </div> <div class="patient-dialogue"> <p>Okay. I will.</p> </div> <div class="note"><i>[Ms. Garcia did not call for a followup appointment nor seek treatment.]</i></div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Treatment Options Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Discussion - A1</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her this is what you need to do for your health</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>This is what you need to do for your health.</p> </div> <div class="patient-dialogue"> <p>My health is fine. I just had one bad night. If my friend hadn't found me I would have just come to on my own and gone about my day.</p> </div> <div class="provider-dialogue"> <p>You are minimizing the situation -- this could have been fatal. I really think it is critical you make an appointment with my office tomorrow.</p> </div> <div class="note"><i>[Ms. Garcia did not call your office nor seek treatment.]</i></div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Treatment Options Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Discussion - B2</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her many patients feel the same way</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Many people in your situation feel the same way. You are not alone. Your doctor will understand your feelings and they will do everything they can to support you.</p> </div> <div class="patient-dialogue"> <p>I guess so.</p> </div> <div class="provider-dialogue"> <p>I know it may seem overwhelming now. However, I think once you enter a treatment program you will find that it is very beneficial. So please call my office for an appointment tomorrow.</p> </div> <div class="note"><i>[Ms. Garcia did not call your office nor seek treatment.]</i></div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Treatment Options Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Discussion - C3</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her how her life would improve if she stopped using alcohol</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>How would your life improve if you were to stop using alcohol?</p> </div> <div class="patient-dialogue"> <p>I guess I'd be less likely to pass out and end up in the ED. Also, I don't like feeling as though I need alcohol to get through the day. I'd like to enjoy my life and not always be thinking about when I'm going to have my next glass of wine. And then there is the insomnia. I'd love to sleep through the night for once.</p> </div> <div class="provider-dialogue"> <p>It sounds like you could really benefit from seeking treatment. I will refer you to a local program.</p> </div> <div class="patient-dialogue"> <p>I think I can give it a try. I'll call them once I'm discharged.</p> </div> <div class="provider-dialogue"> <p>I'm glad to hear that.</p> </div> <div class="note"><i>[Ms. Garcia did not call the program nor seek any treatment.]</i></div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Treatment Options Outcome D]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Discussion - B1</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her that her feelings are not unique</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Your feelings are not unique. Many people in your situation feel the same way. The staff at the intensive outpatient program will understand your feelings and they will do everything they can to support you.</p> </div> <div class="patient-dialogue"> <p>I suppose. It's just so much to think about -- what about my job, my apartment?</p> </div> <div class="provider-dialogue"> <p>I know it may seem overwhelming now. However, I think once you enter the program you will find that it is very beneficial. I can set you up with a referral.</p> </div> <div class="patient-dialogue"> <p>Please don't refer me. I'd rather call the program myself once I'm home.</p> </div> <div class="note"><i>[Ms. Garcia did not call the program nor seek any other treatment.]</i></div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Treatment Options Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Optionss - Discussion - B2</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her that her health is at stake</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Your health is at stake.</p> </div> <div class="patient-dialogue"> <p>My health is fine. I just had one minor fainting episode. If my friend hadn't found me I would have just come to on my own and gone about my day.</p> </div> <div class="provider-dialogue"> <p>You are minimizing the situation -- mixing that alcohol with that medication could have been fatal. I am going to refer you to an intensive outpatient program and I want you to attend the program. You have to do this.</p> </div> <div class="patient-dialogue"> <p>I don't want your referral.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Treatment Options Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Discussion - B3</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her about how stopping alcohol would improve her life</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Talk to me about how stopping alcohol would improve your life.</p> </div> <div class="patient-dialogue"> <p>I guess I'd be less likely to pass out and end up in the ED. Also, I don't like feeling as though I need alcohol to get through the day. I'd like to enjoy my life and not always be thinking about when I'm going to have my next glass of wine. And then there is the insomnia. I'd love to sleep through the night for once.</p> </div> <div class="provider-dialogue"> <p>It sounds like you could really benefit from seeking treatment. Will you try the program?</p> </div> <div class="patient-dialogue"> <p>I think I can give it a try. I'll agree to be admitted.</p> </div> <div class="provider-dialogue"> <p>I'm glad to hear that. </p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Treatment Options Summary G]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Discussion - C1</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her she has to do this for her health</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>You have to do this for your health.</p> </div> <div class="patient-dialogue"> <p>My health is fine. I just had one minor fainting episode. If my friend hadn't found me I would have just come to on my own and gone about my day.</p> </div> <div class="provider-dialogue"> <p> You are minimizing the situation -- this episode could have been fatal. You need to stay as an inpatient. Plus, since you have been drinking regularly for awhile, you may experience some withdrawal symptoms that can be managed by the staff at the inpatient unit to keep you comfortable and medically safe.</p> </div> <div class="patient-dialogue"> <p>No, this is my choice.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Treatment Options Summary H]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Discussion - C2</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Tell her she is not the only one who feels this way</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>You are not the only one who feels this way. Many people in your situation feel the same. The staff in the inpatient treatment unit understand this and they will do everything they can to support you.</p> </div> <div class="patient-dialogue"> <p>I still don't think I need all this treatment.</p> </div> <div class="provider-dialogue"> <p>I know it may seem overwhelming now. However, I think if you stay you will find the treatment to be very beneficial. Plus, since you have been drinking regularly for awhile, you may experience some withdrawal symptoms that can be managed by the staff at the inpatient unit to keep you comfortable and medically safe.</p> </div> <div class="patient-dialogue"> <p>Give me some time. I need to think about this.</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Treatment Options Summary I]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Discussion - C3</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Treatment Options Summary A</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What further treatment would you recommend?</div> <div class="response"><strong>You chose:</strong> Obtaining primary care appointment for treatment of substance use problem</div> Referral back to primary care for either treatment or to act as a medical home for the treatment needed, is a good choice, especially since she is already being treated there for this problem.</div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask her to talk to you about how stopping alcohol would improve your life</div> Asking Ms. Garcia to talk about how not using alcohol would benefit her life was a good way to motivate Ms. Garcia towards seeking treatment.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Inpatient treatment (hospitalization) is appropriate for patients who are at risk for a complicated or serious withdrawal or for patients with a serious medical or psychiatric co-morbidity (Friedmann, 2013). Lengths of stay are typically 4-7 days, after which point patients are transitioned to an ongoing treatment program (BSAS, 2012). Ms. Garcia's current medical status and history together make an inpatient treatment program, at least initially an appropriate treatment. Her high consumption of alcohol, risky mixing of alcohol with a benzodiazepine, and lack of motivation to quit drinking further indicate that she needs a structured environment to quit drinking.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia ED Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Summary - A1a</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Treatment Options Summary B</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What further treatment would you recommend?</div> <div class="response"><strong>You chose:</strong> Obtaining primary care appointment for treatment of substance use problem.</div> Referral back to primary care for either treatment or to act as a medical home for the treatment needed, is a good choice, especially since she is already being treated there for this problem.</div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Tell her this is what you need to do for your health</div> While this is a true statement and talks about a motivation, this is an authoritarian approach rather than patient-centered. Responding to Ms. Garcia's concerns would have been better. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Inpatient treatment (hospitalization) is appropriate for patients who are at risk for a complicated or serious withdrawal or for patients with a serious medical or psychiatric co-morbidity (Friedmann, 2013). Lengths of stay are typically 4-7 days, after which point patients are transitioned to an ongoing treatment program (BSAS, 2012). Ms. Garcia's current medical status and history together make an inpatient treatment program, at least initially an appropriate treatment. Her high consumption of alcohol, risky mixing of alcohol with a benzodiazepine, and lack of motivation to quit drinking further indicate that she needs a structured environment to quit drinking.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia ED Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Summary - A2b</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Treatment Options Summary C</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What fursther treatment would you recommend?</div> <div class="response"><strong>You chose:</strong> Obtaining primary care appointment for treatment of substance use problem.</div> Referral back to primary care for either treatment or to act as a medical home for the treatment needed, is a good choice, especially since she is already being treated there for this problem.</div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> How would you continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Tell her many patients feel the same way</div> This is called normalization and is a good approach to helping patients overcome feelings of shame that are preventing them from taking steps to help themselves. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> Inpatient treatment (hospitalization) is appropriate for patients who are at risk for a complicated or serious withdrawal or for patients with a serious medical or psychiatric co-morbidity (Friedmann, 2013). Lengths of stay are typically 4-7 days, after which point patients are transitioned to an ongoing treatment program (BSAS, 2012). Ms. Garcia's current medical status and history together make an inpatient treatment program, at least initially an appropriate treatment. Her high consumption of alcohol, risky mixing of alcohol with a benzodiazepine, and lack of motivation to quit drinking further indicate that she needs a structured environment to quit drinking.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia ED Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Summary - A3c</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Treatment Options Outcome D</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> What further treatment would you recommend?</div> <div class="response"><strong>You chose:</strong> Referral to intensive outpatient program</div> An outpatient program may not offer sufficient support, medical monitoring, and structure to meet Ms. Garcia's needs at this point. Furthermore, Ms. Garcia has a history of having difficulty following through on referrals.</div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> What would you say to continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Ask her how her life would improve if she stopped using alcohol</div> Asking Ms. Garcia to talk about how quitting alcohol would benefit her life was a good, patient-centered way to try to motivate Ms. Garcia towards seeking treatment.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Inpatient treatment (hospitalization) is appropriate for patients who are at risk for a complicated or serious withdrawal or for patients with a serious medical or psychiatric co-morbidity (Friedmann, 2013). Lengths of stay are typically 4-7 days, after which point patients are transitioned to an ongoing treatment program (BSAS, 2012). Ms. Garcia's current medical status and history together make an inpatient treatment program, at least initially an appropriate treatment. Her high consumption of alcohol, risky mixing of alcohol with a benzodiazepine, and lack of motivation to quit drinking further indicate that she needs a structured environment to quit drinking.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia ED Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Summary - B1d</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Treatment Options Summary E</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong>What further treatment would you recommend?</div> <div class="response"><strong>You chose:</strong> Referral to intensive outpatient program</div> An outpatient program may not offer sufficine support, medical monitoring, and structure to meet Ms. Garcia's needs at this point. Furthermore, Ms. Garcia has a history of having difficulty following through on referrals.</div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> What would you say to continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Tell her that her feelings are not unique</div> Normalizing Ms. Garcia's feelings would be a good way to work with her resistance and ambivalence, but it would have been better to have posed it as "You are not alone." Saying "Your feelings are not unique" sounded dismissive of her emotional distress. </div> <div class="discussion"><strong>Regarding other possible choices:</strong> <p>Inpatient treatment (hospitalization) is appropriate for patients who are at risk for a complicated or serious withdrawal or for patients with a serious medical or psychiatric co-morbidity (Friedmann, 2013). Lengths of stay are typically 4-7 days, after which point patients are transitioned to an ongoing treatment program (BSAS, 2012). Ms. Garcia's current medical status and history together make an inpatient treatment program, at least initially an appropriate treatment.</p><p>Another choice, asking Ms. Garcia how her life would improve if she were to stop using alcohol would have been an effective approach to motivating her. This would have elicited her own motivations for seeking treatment.</p></div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia ED Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Summary - B2e</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Treatment Options Summary F</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> What further treatment would you recommend?</div> <div class="response"><strong>You chose:</strong> Referral to intensive outpatient program</div> An outpatient program may not offer sufficient support, medical monitoring, and structure to meet Ms. Garcia's needs at this point. Furthermore, Ms. Garcia has a history of having difficulty following through on referrals. </div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> What would you say to continue the conversation with Ms. Garcia?</div> <div class="response"><strong>You chose:</strong> Tell her that her health is at stake</div> If instead of being authoritarian and forceful with Ms. Garcia, you had tried to elicit Ms. Garcia's motivations for wanting to stop using alcohol or normalized her feelings by letting her know that she is not alone. This would have increased her chances of seeking treatment.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Inpatient treatment (hospitalization) is appropriate for patients who are at risk for a complicated or serious withdrawal or for patients with a serious medical or psychiatric co-morbidity (Friedmann, 2013). Lengths of stay are typically 4-7 days, after which point patients are transitioned to an ongoing treatment program (BSAS, 2012). Ms. Garcia's current medical status and history together make an inpatient treatment program, at least initially an appropriate treatment. Her high consumption of alcohol, risky mixing of alcohol with a benzodiazepine, and lack of motivation to quit drinking further indicate that she needs a structured environment to quit drinking.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia ED Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Summary - B3f</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Treatment Options Summary G</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What further treatment would you recommend?</div> <div class="response"><strong>You chose:</strong> Inpatient hospitalization</div> Inpatient treatment (hospitalization) is appropriate for patients who are at risk for a complicated or serious withdrawal or for patients with a serious medical or psychiatric co-morbidity (Friedmann, 2013). Lengths of stay are typically 4-7 days, after which point patients are transitioned to an ongoing treatment program (BSAS, 2012). Ms. Garcia's current medical status and history together make an inpatient treatment program, at least initially, an appropriate treatment. Her high consumption of alcohol, risky mixing of alcohol with a benzodiazepine, and lack of motivation to quit drinking further indicate that she needs a structured environment to quit drinking.</div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> How would you continue the conversation?</div> <div class="response"><strong>You chose:</strong> Ask her about how stopping alcohol would improve her life.</div> Asking her to tell you how her life would benefit from not using alcohol was a good step towards motivating her to seek treatment.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Normalizing her feelings by letting her know that she is not alone in the way she feels is another, often effective way to work with patient resistance. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia ED Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Summary - C1g</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Treatment Options Summary H</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What further treatment would you recommend?</div> <div class="response"><strong>You chose:</strong> Inpatient hospitalization</div> Inpatient treatment (hospitalization) is appropriate for patients who are at risk for a complicated or serious withdrawal or for patients with a serious medical or psychiatric co-morbidity (Friedmann, 2013). Lengths of stay are typically 4-7 days, after which point patients are transitioned to an ongoing treatment program (BSAS, 2012). Ms. Garcia's current medical status and history together make an inpatient treatment program, at least initially, an appropriate treatment. Her high consumption of alcohol, risky mixing of alcohol with a benzodiazepine, and lack of motivation to quit drinking further indicate that she needs a structured environment to quit drinking.</div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> How would you continue the conversation?</div> <div class="response"><strong>You chose:</strong> Tell her she has to do this for her health</div> If, instead of being authoritarian and forceful with Ms. Garcia, you had tried to elicit Ms. Garcia's motivations for wanting to stop using alcohol or normalized her feelings by letting her know that she is not alone, it would have increased her chances of seeking treatment.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Asking Ms. Garcia how her life would improve if she were to stop using alcohol is also effective. This would have elicited her own motivations for seeking treatment and would have increased her chances of agreeing to treatment.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia ED Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Summary - C2h</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Treatment Options Summary I</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What further treatment would you recommend?</div> <div class="response"><strong>You chose:</strong> Inpatient hospitalization</div> Inpatient treatment (hospitalization) is appropriate for patients who are at risk for a complicated or serious withdrawal or for patients with a serious medical or psychiatric co-morbidity (Friedmann, 2013). Lengths of stay are typically 4-7 days, after which point patients are transitioned to an ongoing treatment program (BSAS, 2012). Ms. Garcia's current medical status and history together make an inpatient treatment program, at least initially, an appropriate treatment. Her high consumption of alcohol, risky mixing of alcohol with a benzodiazepine, and lack of motivation to quit drinking further indicate that she needs a structured environment to quit drinking.</div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> How would you continue the conversation?</div> <div class="response"><strong>You chose:</strong> Tell her she is not the only one who feels this way</div> Normalizing Ms. Garcia's feelings is an effective approach to working with resistance and ambivalence. Saying, "You are not alone" is a more compassionate way to put it, however.</div> <div class="discussion"><strong>Regarding other possible choices:</strong> Another approach, asking Ms. Garcia how her life would improve if she were to stop using alcohol is also effective. This would have elicited her own motivations for seeking treatment and would have increased her chances of agreeing to treatment.</div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia ED Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three Treatment Options - Summary - C3I</p> <div class="chapter"><strong>Ch 11 |</strong> Event Three Treatment Options</div><div class="progress chapter11"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia ED Summary</div> <div class="container"> <div class="inner"> <div class="content"><p><strong>Patient Info/CC/HPI (Subjective):</strong> 47 yowf brought to the ED after being found semi-conscious with reduced responsiveness. Recovered before arriving in ED partially alert and slightly poorly orientated state (situation). Patient had failed to follow up on previous referrals for treatment for mild substance use disorder and has history of not being forthcoming regarding the extent of her alcohol use. She admitted to drinking a bottle of wine and taking an alprazolam.</p><p><strong>P.E./Labs/Meds/Screening (Objective):</strong> Labs increased MCV, elevated ALT, BAC 0.1%, blood test positive for benzodiazepines.</p><p><strong>Differential (Assessment):</strong> Intoxicated per legal limits from alcohol plus alprazolam (non-medical use). Lab results consistent with chronic, excessive alcohol use. </p><p><strong>Brief Interventions/Treatment (Plan):</strong> Admitted for acute hospitalization, inpatient unit which will determine plan for future care.</p></div></div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Patient Encounter Summary]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Event Three ED Summary</p> <div class="chapter"><strong>Ch 12 |</strong> Maria Garcia ED Summary</div><div class="progress chapter12"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Maria Garcia Patient Encounter Summary</div> <div class="container"> <div class="inner"> <div class="ehr"> <div class="header patientimg"> <h4>Case Summary</h4> <div class="patientname"></div> </div> <div class="content"><p><strong>Patient Info/CC/HPI (Subjective):</strong> 47 yowf originally complained of insomnia, with stress and alcohol use apparent contributing factors. Had not tried prescription sleep medications, but non-responsive to OTC sleep aids. Returned when unable to cut back on alcohol use as recommended and continued to suffer from insomnia. Later was brought to the ED after being found unconscious and unresponsive. Recovered before arriving in partially alert and slightly poorly orientated state (place). Patient had failed to follow up on previous referrals for treatment for mild substance use disorder and has history of not being forthcoming regarding the extent of her alcohol use.</p><p><strong>P.E./Labs/Meds (Objective):</strong> All physical exam findings were within normal limits at first appointment. Blood tests to be discussed in later visit. Significant results from blood test discussed during second visit: elevated MCV and AST. Revised alcohol use assessment confirmed excessive alcohol use, beyond recommended weekly limits and limits for single occasions. ER visit labs (MCV, ALT), BAC 0.1%, blood test positive for benzodiazepines.</p><p><strong>Differential (Assessment):</strong> Insomnia secondary to alcohol use and mild alcohol use disorder. Upon ER visit, found to be legally intoxicated from alcohol plus alprazolam (non-medical use). Lab results consistent with chronic, excessive alcohol use.</p><p><strong>Brief interventions/Treatment (Plan):</strong> Trial of alcohol abstinence. Labs ruled out hyperthyroid. Re-evaluation in 1 week revealed greater alcohol intake, mild alcohol use disorder, and led to referral to addiction specialist for treatment. Referral letter informed addiction specialist of: Ms. Garcia's history of being dishonest about her alcohol use, Ms. Garcia's NIAAA screening results suggesting at least mild alcohol use disorder, the results of Ms. Garcia's blood tests which suggest heavy alcohol consumption, Ms. Garcia's history if insomnia, the results of Ms. Garcia's physical exam, and Ms. Garcia's past attempts to quit drinking and improve her sleep. she did not follow through with her referral. No response to several attempts at follow-up phone calls. Later admitted to hospital for acute alcohol plus benzodiazepine intoxication hospitalization. Inpatient unit will determine followup plan for ongoing alcohol use disorder and insomnia.</p></div></div></div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Case References]]</div> <div class="continue">[[Finish and Take Survey]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Maria Garcia Patient Encounter Summary</p> <div class="chapter"><strong>Ch 13 |</strong> Maria Garcia Patient Encounter Summary</div><div class="progress chapter13"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Ask her to tell more about her alcohol consumption</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Please tell me more about your alcohol consumption, as it may be relevant to your sleep problem.</p> </div> <div class="patient-dialogue"> <p>I like to have a glass or two of wine in the evenings before bed. The wine helps me relax and fall asleep. If I didn't have it, I'd have more trouble falling asleep. </p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[History Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient - Discussion - B3</p> <div class="chapter"><strong>Ch 1 |</strong> History</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice">Case Overview</div> <div class="container case"> <div class="inner"> <div class="report"> <h4 class="title">Case Overview</h4> <div class="patient-overview"> <div class="patientimg"></div> <div class="name">Maria</div> <div class="age">Age 47</div> <div class="occupation">Educational manager</div> <div class="complaint">"I just can't seem to deal with this insomnia."</div> </div><p>In this clinical simulation, you will act as Ms. Garcia's primary care provider and experience outcomes based on which choices you make. You will be challenged to:</p><p> <ol><li>Develop a trusting relationship with Ms. Garcia</li><li>Discuss her personal health habits with her</li<li>Identify and treat the cause of her insomnia and any other medical problems discovered.</li></ol></p> <div class="continue">[[Meet Your Patient and History]]</div> <div style="clear:both;"></div> </div> </div> </div>

<div class="yourchoice"><strong>You chose:</strong> Evaluation: Screening and Assessment</div> <div class="container"> <div class="inner"> <div class="note">Since a likely diagnosis for Ms. Garcia is insomnia secondary to alcohol consumption, you decide to use the National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2005) screening instrument to formally investigate her alcohol consumption.</div> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Because alcohol may be contributing to your insomnia, I would like to ask you more about your alcohol consumption. Would that be okay?</p> </div> <div class="patient-dialogue"> <p>I thought we already covered all of that? What else would you like to know?</p> </div> <div class="provider-dialogue"> <p>I have a series of questions to ask that would help. How many days in the past year would you say that you've had more than 4 drinks at one time?</p> </div> <div class="patient-dialogue"> <p>Only once. I was at a wedding and didn't realize that the waiter kept refilling my glass until it was too late.</p> </div> <div class="provider-dialogue"> <p>Okay, thank you. Now, you said that you have 1-2 glasses of wine before bed at night every night, so you average between 7-14 drinks per week?</p> </div> <div class="patient-dialogue"> <p>Yes, that's correct. Probably around 9 drinks per week.</p> </div> </div> </div> <div class="navigation"> <div class="question">Given her answers, how would you assess Ms. Garcia?</div> <div class="continue">[[Further screening for alcohol use disorder]] </div> <div class="continue">[[She is a binge drinker]] </div> <div class="continue">[[No need of further alcohol screening]]</div></div> </div> <div class="footer"> <p class="small">You are here: NIAAA Screening and Assessment</p> <div class="chapter"><strong>Ch 3 |</strong> NIAAA Screening and Assessment</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Case References</div> <div class="container"> <div class="inner"> <div class="references"> <p>BSAS. SBIRT: A Step-By-Step Guide. <i>MASBIRT</i>. 2012. Available at: http://www.masbirt.org/sites/www.masbirt.org/files/documents/toolkit.pdf Accessed on: 2015-03-19.</p> <p>Burns E, Gray R, Smith LA. Brief screening questionnaires to identify problem drinking during pregnancy: a systematic review. <i>Addiction.</i> 2010; 105(4): 601-604. Available at: http://onlinelibrary.wiley.com/enhanced/doi/10.1111/j.1360-0443.2009.02842.x/ Accessed on: 2015-12-14.</p> <p>Centers For Disease Control and Prevention. Facts Sheets - Binge Drinking. <i>Alcohol & Public Health - Facts Sheets.</i> 2015. Available at: http://www.cdc.gov/alcohol/fact-sheets/binge-drinking.htm Accessed on: 2015-12-21.</p> <p>Chan AWK, Pristach EA, Welte JW, et al., (1993). Use of the TWEAK Test in Screening for Alcoholism/Heavy Drinking in Three Populations. Alcoholism. 17(6): 1188-1192. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.1993.tb05226.x/abstract</p> <p>Ewing, J.A. Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association. 1984. 252, 1905–1907. Available at: http://www.ncbi.nlm.nih.gov/pubmed/6471323</p> <p>Ferracioli-Oda, E, Qawasmi, A, Bloch, MH. Meta-Analysis: Melatonin for the Treatment of Primary Sleep Disorders. <i>PLOS One.</i> 2013; 8(5): e63773. Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0063773</p> <p>Friedmann PD. Alcohol use in adults. <i>N Engl J Med.</i> 2013; 368: 365-373. Available at: http://www.nejm.org/doi/full/10.1056/NEJMcp1204714 Accessed on: 2015-06-24.</p> <p>Hilty D, Young JS, Bourgeois JA, et al. Algorithms for the assessment and management of insomnia in primary care. <i>Patient Preference and Adherence.</i> 2009; 3: 9-20. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2778437/pdf/ppa-3-009.pdf Accessed on: 2016-01-07.</p> <p>Jones, CM, Paulozzi, LJ, Mack, KA. Alcohol Involvement in Opioid Pain Reliever and Benzodiazepine Drug Abuse-Related Emergency Department Visits and Drug- Related Deaths - United States, 2010. <i>Morbidity and Mortality Weekly Report.</i> 2014; 63(40): 881-885. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6340a1.htm Accessed on: 2015-11-20.</p> <p>Lei JD, Tu Kn, Shen DD, et al.. Pharmacological Treatment of Insomnia. <i>Pharmacy and Therapeutics.</i> 2015; 40(11): 759-769, 771. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634348/ Accessed on: 2015-12-22.</p> <p>McKay, JR, Hiller-Sturmhofel, S. Treating Alcoholism as a Chronic Disease. <i>Alcohol Research and Health</i>. 2011; 33(4): 356-370. Available at: http://pubs.niaaa.nih.gov/publications/arh334/356-370.pdf Accessed on: 2016-01-05.</p> <p>NHLBI. Insomnia: Assessment and Management in Primary Care. <i>American Family Physician.</i> 1999; 59(11): 3029-3038. Available at: http://www.aafp.org/afp/1999/0601/p3029.html Accessed on: 2015-12-14.</p> <p>NIAAA. Alcohol and Sleep. <i>Alcohol Alert</i>. 1998; 41. Available at: http://pubs.niaaa.nih.gov/publications/aa41.htm Accessed on: 2015-11-09.</p> <p>NIAAA. Alcohol Facts and Statistics. <i>NIAAA</i>. 2015. Available at: http://pubs.niaaa.nih.gov/publications/AlcoholFacts&Stats/AlcoholFacts&Stats.pdf Accessed on: 2015-04-29.</p> <p>NIAAA. Alcohol Overdose: The Dangers of Drinking Too Much. October 2015. Available at: http://pubs.niaaa.nih.gov/publications/AlcoholOverdoseFactsheet/Overdosefact.htm Accessed on: 2015-12-11.</p> <p>NIAAA Screen. A Pocket Guide for Alcohol Screening and Brief Intervention. National Institute on Alcohol Abuse and Alcoholism. 2005. Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/PocketGuide/pocket_guide.htm Accessed 6/6/2016.</p> <p>Ramakrishnan K, Scheid D. Treatment Options for Insomnia. <i>American Family Physician</i>. 2007; 76(4): 517-526. Available at: http://www.aafp.org/afp/2007/0815/p517.html Accessed on: 2015-12-22.</p> <p>Riper H, Andersson G, Hunter SB, et al. Treatment of comorbid alcohol use disorders and depression with cognitive-behavioural therapy and motivational interviewing: a meta-analysis. <i>Addiction.</i> 2013; 109: 394-406. Available at: http://onlinelibrary.wiley.com/doi/10.1111/add.12441/pdf Accessed on: 2015-12-14.</p> <p>Smagula SF, Stone KL, Fabio A, et al. Risk Factors for sleep disturbances in older adults: Evidence from prospective studies. <i>Sleep Medicine Reviews</i>. 2015 Jan 15; Epub ahead of print: . Available at: http://www.smrv-journal.com/article/S1087-0792(15)00015-5/abstract Accessed on: 2016-01-07.</p> <p>Stein MD, Friedman PD. Disturbed Sleep and Its Relationship to Alcohol Use. <i>Substance Abuse.</i> 2005; 26(1): 1-13. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775419/ Accessed on: 2015-12-18.</p> <p>USDA. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. 2015. Available at: http://health.gov/dietaryguidelines/2015-scientific-report/pdfs/scientific-report-of-the-2015-dietary-guidelines-advisory-committee.pdf Accessed on: 2015-11-21.</p> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Finish and Take Survey]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Case References</p> <div class="chapter"><strong>Ch 13 |</strong> Maria Garcia Patient Encounter Summary</div><div class="progress chapter13"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice"><strong>You chose:</strong> Quiz</div> <div class="container"> <div class="inner"> <div class="results"> Use the skills you learned with this patient to answer the questions below. <strong>1. Which of the following patient statements reveals that they are experiencing one of the criteria for an alcohol use disorder?</strong> A. "I do not keep track of how much I drink" B. "I know alcohol makes my heartburn worse but I still drink anyway"<br/> C. "It is true that I drink alcohol every day"<br/> D. "I only drink when I am stressed out"<br/> <strong>2. You just diagnosed Mr. Ruse with a mild alcohol use disorder and recommended that he see a counselor who treats alcohol use disorders. Of the referral strategies listed below, which one is most likely to result in Mr. Ruse following through with with your recommendation?</strong><br/> A. Advise Mr. Ruse to contact his insurance company for list of counselors on his health plan<br/> B. Obtain his consent and have your office directly refer Mr. Ruse to a counselor<br/> C. Provide Mr. Ruse with the contact information for a counselor<br/> D. Plan to call Mr. Ruse in a month to ask if he has seen a counselor<br/> <strong>3. Which of the following symptoms is not characteristic of an acute alcohol and benzodiazepine interaction?</strong><br/> A. Loss of consciousness<br/> B. Unresponsiveness<br/> C. Memory loss<br/> D. Hyperphagia<br/> <strong>4. John is 45 years old and has been a patient in your office for several years. When John first started at your clinic, he was classified as abusing alcohol. Lately, based on what John has told you, you suspect that John is now dependent on alcohol. To corroborate the initial diagnosis, please choose which laboratory test is the most specific for indicating heavy alcohol use?</strong><br/> A. GGT (gamma-glutamyl transferase)<br/> B. MCV (mean corpuscular volume)<br/> C. CDT (carbohydrate deficient transferrin)<br/> D. EtG (Ethylglucuronide)<br/> --- </div> </div> <div class="navigation"> <div class="continue">[[Quiz Feedback]]</div></div> </div><div class="footer"> <p class="small">You are here: Quiz</p> <div class="chapter"><strong>Ch 13 |</strong> Maria Garcia Patient Encounter Summary</div><div class="progress chapter13"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div></div>

<div class="yourchoice"><strong>You chose:</strong> Quiz Feedback</div> <div class="container"> <div class="inner"> <div class="results"> <strong>1. Which of the following patient statements reveals that they are experiencing one of the criteria for an alcohol use disorder?</strong><br/> //YOU CHOSE: A. "I do not keep track of how much I drink"//<br/> FEEDBACK: Inability to report how much alcohol one consumes is not one of the criteria for an alcohol use disorder. <br/> //YOU CHOSE: B. "I know alcohol makes my heartburn worse but I still drink anyway"//<br/> FEEDBACK: Correct. Drinking despite negative health consequences of alcohol use is one of the criteria for an alcohol use disorder (APA, 2013). Since the patient drinks in spite of the painful gastric consequences, they are experiencing this symptom of an alcohol use disorder. <br/> //YOU CHOSE: C. "It is true that I drink alcohol every day"//<br/> FEEDBACK: While it can be a warning symptom, daily alcohol consumption is not one of the criteria for an alcohol use disorder.<br/> //YOU CHOSE: D. "I only drink when I am stressed out"//<br/> FEEDBACK: Drinking to cope with stress is not one of the criteria for an alcohol use disorder. <br/> --- <strong>2. You just diagnosed Mr. Ruse with a mild alcohol use disorder and recommended that he see a counselor who treats alcohol use disorders. Of the referral strategies listed below, which one is most likely to result in Mr. Ruse following through with with your recommendation?</strong><br/> //YOU CHOSE: A. Advise Mr. Ruse to contact his insurance company for list of counselors on his health plan//<br/> FEEDBACK: While health insurance is a consideration, this is not the most effective approach. Even if he follows your advice, the list of counselors provided by the insurance company may not be specific for alcohol use disorders.<br/> //YOU CHOSE: B. Obtain his consent and have your office directly refer Mr. Ruse to a counselor//<br/> FEEDBACK: Correct. Provider assistance in locating and coordinating care has been shown to increase retention rates of patients seeking treatment for alcohol use disorders (McKay & Hiller-Sturmhofel, 2011). Thus, obtaining his consent and directly referring Mr. Ruse maximizes the chances that he will seek treatment. Furthermore, by obtaining his consent and contacting the counselor you are setting the foundation for a multidisciplinary team to treat Mr. Ruse's alcohol use disorder.<br/> //YOU CHOSE: C. Provide Mr. Ruse with the contact information for a counselor//<br/> FEEDBACK: While he may choose to contact the counselor, contacting the counselor on his behalf increases his chances of seeking treatment. Additionally, it is best to coordinate care with a patient's other providers.<br/> //YOU CHOSE: D. Plan to call Mr. Ruse in a month to ask if he has seen a counselor//<br/> FEEDBACK: While it is important to follow up with patients, this plan places the onus on Mr. Ruse to seek out and see a counselor.<br/> --- <strong>3. Which of the following symptoms is not characteristic of an acute alcohol and benzodiazepine interaction?</strong><br/> //YOU CHOSE: A. Loss of consciousness//<br/> FEEDBACK: Loss of consciousness is a symptom of an acute alcohol and benzodiazepine interaction.<br/> //YOU CHOSE: B. Unresponsiveness//<br/> FEEDBACK: Unresponsiveness is associated with an acute alcohol and benzodiazepine interaction.<br/> //YOU CHOSE: C. Memory loss//<br/> FEEDBACK: Memory loss can occur following an acute alcohol and benzodiazepine interaction.<br/> //YOU CHOSE: D. Hyperphagia//<br/> FEEDBACK: Correct. Hyperphagia is not a symptom of an alcohol and benzodiazepine interaction.<br/> --- <strong>4. John is 45 years old and has been a patient in your office for several years. When John first started at your clinic, he was classified as abusing alcohol. Lately, based on what John has told you, you suspect that John is now dependent on alcohol. To corroborate the initial diagnosis, please choose which laboratory test is the most specific for indicating heavy alcohol use?</strong><br/> //YOU CHOSE: A. GGT (gamma-glutamyl transferase)//<br/> FEEDBACK: Incorrect. Although the GGT test may be used to screen for liver damage, the CDT test has the highest specificity.<br/> //YOU CHOSE: B. MCV (mean corpuscular volume)//<br/> FEEDBACK: Incorrect. The MCV test is used to determine the average volume of red blood cells in a given sample. <br/> //YOU CHOSE: C. CDT (carbohydrate deficient transferrin)//<br/> FEEDBACK: Correct. The CDT test has the highest specificity.<br/> //YOU CHOSE: D. EtG (Ethylglucuronide)//<br/> FEEDBACK: Incorrect. The EtG test has high specificity, but is known for a high false positive rate.<br/> ---</div> </div> <div class="navigation"> <div class="continue">[[Survey]]</div></div> </div><div class="footer"> <p class="small">You are here: Quiz Feedback</p> <div class="chapter"><strong>Ch 13 |</strong> Maria Garcia Patient Encounter Summary</div><div class="progress chapter13"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div></div>

<div class="yourchoice"><strong>You chose:</strong> Survey</div> <div class="container"> <div class="inner"> <div class="results"> <ol> <li>The cases achieved the learning objectives <ul> <li>N/A</li> <li>Strongly Disagree</li> <li>Disagree</li> <li>Neither Agree or Disagree</li> <li>Agree</li> <li>Strongly Agree</li> </ul> </li> <li>I understood the choices I was presented <ul> <li>N/A</li> <li>Strongly Disagree</li> <li>Disagree</li> <li>Neither Agree or Disagree</li> <li>Agree</li> <li>Strongly Agree</li> </ul> </li> <li>I enjoyed working through the cases <ul> <li>N/A</li> <li>Strongly Disagree</li> <li>Disagree</li> <li>Neither Agree or Disagree</li> <li>Agree</li> <li>Strongly Agree</li> </ul> </li> <li>The cases were a valuable learning experience <ul> <li>N/A</li> <li>Strongly Disagree</li> <li>Disagree</li> <li>Neither Agree or Disagree</li> <li>Agree</li> <li>Strongly Agree</li> </ul> </li> </ol> </div> </div> <div class="navigation"> </div> </div> <div class="footer"> <p class="small">You are here: Survey</p> <div class="chapter"><strong>Ch 13 |</strong> Maria Garcia Patient Encounter Summary</div><div class="progress chapter13"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div></div>

<div class="yourchoice"><strong>You chose:</strong> Talk about alternative treatments for insomnia</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Okay. Well, we can talk about some other treatments for insomnia.</p> </div> <div class="patient-dialogue"> <p>Sure, how about some medication?</p> </div> </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Maria Garcia Appointment Two Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Appointment Two History - Discussion - B2</p> <div class="chapter"><strong>Ch 6 |</strong> Maria Garcia Appointment Two</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div> <div class="chaptermark5"></div><div class="chaptermark6"></div></div> </div>

<div class="yourchoice welcome"><strong>Welcome to</strong> Clinical Encounters: Alcohol</div><div class="container intro welcome"> <div class="inner"> <div class="welcomeimg"></div> </div> <div class="navigation"> </div> </div> <style> tw-story { background: url('http://docs.clinicaltools.com/images/project/clinicalencounter/introbackground.jpg') no-repeat center center; } tw-passage { background: transparent; } </style>

<div class="yourchoice">Getting Started</div> <div class="container"> <div class="inner"> <div class="summary closebox"> <div class="close">[[ |Get Started]]</div> <h2 class="title">Instructions</h2> <div class="summary"><strong>Instructions:</strong> Move through this patient visit by choosing responses to questions at the bottom of each passage. Continue to the end of the case (Case Summary) to find a link to the survey.</div> <div class="summary"><strong>Feedback on Mastery:</strong> You will complete typical steps of a patient encounter and receive feedback after each step: review case history, complete an evaluation, diagnosis, and brief intervention, and make a plan of care for your patient. Feedback on your choices will be color coded as follows: </div> <div class="feedback correct third start"> <div class="response">Best Selection</div> </div><div class="clear"></div> <div class="feedback neutral third"> <div class="response">Less Than Ideal Selection</div> </div><div class="clear"></div> <div class="feedback incorrect third end"> <div class="response">Incorrect Selection</div> </div><div style="clear:both;"></div> <div class="return">[[Back|Get Started]]</div> </div> </div> </div> <style> tw-passage { background: #e1e1e1; background: -webkit-linear-gradient(left top, rgb(205, 221, 216), #e1e1e1); background: -o-linear-gradient(bottom right, rgb(205, 221, 216), #e1e1e1); background: -moz-linear-gradient(bottom right, rgb(205, 221, 216), #e1e1e1); background: linear-gradient(to bottom right, rgb(205, 221, 216), #e1e1e1); } </style>

<div class="version">v 2.0</div> <div class="welcomeheader" id="alcohol"></div> <div class="container intro welcome new"> <div class="inner">  <div class="welcomeimg patientbox"> <div class="patientimg"></div> <div class="patientinfo"> <strong>Maria</strong> <p>"I just can't seem to deal with this insomnia."</p> <div class="continue">[[Begin Case|Case Overview]]</div> </div> </div>  <div class="welcomeimg patientbox inactive"> <div class="patientimg pt2"></div> <div class="patientinfo"> <strong>Abraham</strong> <p>"Drinking just a little won't affect my blood pressure, right?"</p> <div class="continue fakebutton"> <div>Available In Store</div> </div> </div> </div>  <div class="welcomeimg patientbox inactive"> <div class="patientimg alice"></div> <div class="patientinfo"> <strong>Alice</strong> <p>"I've been getting a lot of headaches, probably from stress."</p> <div class="continue fakebutton"> <div>Available In Store</div> </div> </div> </div>  <div class="welcomeimg patientbox inactive"> <div class="patientimg pt4"></div> <div class="patientinfo"> <strong>Tommy</strong> <p>"My headaches don't last long, but they're driving me crazy!"</p> <div class="continue fakebutton"> <div>Available In Store</div> </div> </div> </div> <div class="info">[[Instructions]]</div> <div class="note">Funding: Development supported by NIAAA grant #R43AA020456. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.</div> </div> </div> <style> tw-passage { background: #e1e1e1; background: -webkit-linear-gradient(left top, rgb(205, 221, 216), #e1e1e1); background: -o-linear-gradient(bottom right, rgb(205, 221, 216), #e1e1e1); background: -moz-linear-gradient(bottom right, rgb(205, 221, 216), #e1e1e1); background: linear-gradient(to bottom right, rgb(205, 221, 216), rgba(225, 225, 225, 0.85)); } </style>

<div class="container completed"> <div class="inner"> <div class="summary">You have completed the case of Maria Garcia. <strong>When finished: <a href="https://alcohol.clinicalencounters.com/clinical-encounters-alcohol-survey/" target="_blank">Be Sure to Complete the Survey</a></strong> <div class="return">[[Retake The Experience|Case Overview]]</div> </div> </div> </div>

<div class="yourchoice"><strong>You chose:</strong> Evaluation Dialogue</div> <div class="container"> <div class="inner"> <div class="note">If you had chosen correctly, the dialogue would have been the following:</div> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Has your drinking ever led you to having an accident or bodily harm or trouble with the law?</p> </div> <div class="patient-dialogue"> <p>No, nothing like that.</p> </div> <div class="provider-dialogue"> <p>Relationship or work problems? </p> </div> <div class="patient-dialogue"> <p>No.</p> </div> <div class="provider-dialogue"> <p>Do you find you are drinking more to get the same effect?</p> </div> <div class="patient-dialogue"> <p>No. It's always one to two glasses. I stick with that limit.</p> </div> <div class="provider-dialogue"> <p>Have you found that you experience withdrawal when you don't drink?</p> </div> <div class="patient-dialogue"> <p>I've never really quit drinking, but I don't think I would go into withdrawal if I did quit.</p> </div> <div class="provider-dialogue"> <p>Do you keep drinking despite it causing problems?</p> </div> <div class="patient-dialogue"> <p>No, it really doesn't cause any problems. <i>[She's beginning to sound irritated.]</i></p> </div> <div class="provider-dialogue"> <p>Do you spend significant time drinking?</p> </div> <div class="patient-dialogue"> <p>No.</p> </div> <div class="provider-dialogue"> <p>Do you prioritize alcohol over more important matters?</p> </div> <div class="patient-dialogue"> <p>No. I go about my day and then I relax with some wine at night.</p> </div></div> <div class="note"> In summary, Ms. Garcia screened negatively for needing further alcohol assessment. </div> </div> <div class="navigation"><div class="question"> Continue to:</div> <div class="continue">[[Brief Intervention]]</div> </div> </div> <div class="footer"><p class="small">You are here: NIAAA Screening and Assessment - Summary - BC</p><div class="chapter"><strong>Ch 3 |</strong> NIAAA Screening and Assessment</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div></div>

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