community health case study

Case Study: John Riley

An inner-city emergency department (ED) receives a report about an incoming 72-year-old man

found disoriented, smelling of alcohol, and with a suspected hip fracture. Upon arrival to the ED, the

patient, John Riley, has a blood alcohol level (BAL) of 0.17. He is 6 feet 1 inch tall and weighs 180

pounds. The ED doctor completes and x-ray of John’s hip and does not find a fracture; however, the

doctor notes old bruising on his arms and legs. His liver function tests of alanine aminotransferase (ALT)

and aspartate aminotransferase (AST) are elevated (ALT = 53 IU/L and AST = 40 IU/L) so an additional

gamma-glutamyltransferase (GGT) is ordered, indicating an elevated level at 72 IU/L.

1. What are the characteristic signs and symptoms of impaired liver function?

The psych liaison nurse, Rob Pearson, RN, is paged to complete a psych evaluation on John to

find out more about his alcohol consumption. John reports he only had two glasses of wine


2. Rob knows that John is minimizing his alcohol use and refers to alcohol-content-(bac) to estimate his actual consumption from the BAC Table for Men. Rob finds John has really consumed how many drinks?

3. What does Rob realize about the importance of accurate alcohol screening?

4. Rob understands that his questions should focus on which of the following?

a. Making John admit to his “real” alcohol consumption

b. Increasing Johns’ feelings of guilt over his drinking, which will help him learn to stop

c. John’s perceptions of his drinking behaviors and the consequences of his drinking

d. Teaching John the alcohol content in one drink

Rob finds that John is drinking daily by administering the CAGE questionnaire (Ewing, 1984). He


Have you ever felt you should Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt bad or Guilty about your drinking?

Have you ever had and Eye-opener drink first thing in the morning to steady your nerves or get rid of a hangover?

John states that he feels like he should cut down on his drinking and his daughter is constantly

“on his case” about how much he drinks. He states, “If only I had the resources and ability to stop.” John

feels that he began drinking after his wife died two years ago. John relates when he tries to stop

drinking, his hands start to shake, and he drinks a glass of wine to steady his nerves. He reports drinking

seven to eight glasses of wine, on average, daily. The maximum amount John reports consuming is one

gallon of wine.

5. What is one alcoholic drink defined as?

6. What are the potential risks with habitual and/or excessive alcohol use?

7. What additional signs and symptoms of alcohol-related abuse or dependence might be evident in the initial assessment?

Rob completes the Short Michigan Alcoholism Screening Test – Geriatric Version (SMAST-G) on John (…Alcoholism%20Screening%20Test%20Geriatric%20Version.pdf ; Blow, 1991). John scores 9 out of 10,

indicating alcohol is a problem. Rob also knows John has been drinking daily since his wife’s death.

The American Psychological Association (APA) published the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May, 2013. A major change from the earlier edition was that alcohol use disorders were broken down into two categories: alcohol abuse and alcohol dependence. According to the APA, the distinction between abuse and dependence was based on the concept of abuse as a mild or early phase, and dependence as the more severe manifestation. The most recent manual has a single diagnosis of alcohol abuse disorder which, according to the APA, will better match the symptoms that patients experience (Buddy, 2013).

8. Use the following web link to determine what criteria of the 11 identified must be met for John to be classified as having an alcohol abuse disorder:

John states he will simply stop drinking on his own at home.

9. Rob strongly encourages John to transfer to the hospital’s mental health floor and explains to John that receiving additional medical attention is imperative, because, if he attempts to stop drinking at home, he is at the highest risk for the following:

a. Withdrawal

b. Continuing to drink

c. Becoming nutritionally impaired

d. Increasing his isolation, putting him at risk for depression.

John agrees to enter the detox program and signs in voluntarily for a transfer to the unit.

Suggested Resources

Blow, F. C. (1991).Short Michigan Alcohol Screening Test-Geriatric Version (SMAST-G).Ann Arbor, MI:

University of Michigan Alcohol Research Center.Buddy, T. (2013).DSM-5 substance abuse disorders draws controversy. Alcoholism.Retrievedfrom

Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire.Journal of the American MedicalAssociation, 252,1905-1907.