CASE INFORMATION

Case ID: ALCOHOL-2025-14
Case Name: David Mitchell
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P15 (Chronic Alcohol Abuse)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages effectively with the patient to assess alcohol use and related health concerns 1.3 Uses a non-judgmental and motivational interviewing approach to discuss alcohol dependence 1.5 Uses shared decision-making regarding harm reduction and treatment options
2. Clinical Information Gathering and Interpretation	2.1 Conducts a structured history to assess alcohol use, dependence, and complications 2.3 Identifies physical and psychological sequelae of chronic alcohol abuse
3. Diagnosis, Decision-Making and Reasoning	3.1 Diagnoses alcohol use disorder based on history and assessment tools 3.5 Recognises when urgent intervention (e.g., withdrawal management) is required
4. Clinical Management and Therapeutic Reasoning	4.2 Develops an individualised management plan incorporating pharmacological and non-pharmacological strategies 4.5 Refers to appropriate support services, including counselling and rehabilitation
5. Preventive and Population Health	5.1 Provides education on alcohol-related harm reduction strategies 5.3 Discusses screening and preventive measures for alcohol-related conditions
6. Professionalism	6.1 Provides compassionate care while maintaining professional boundaries
7. General Practice Systems and Regulatory Requirements	7.1 Documents alcohol use and treatment plan in line with medico-legal requirements 7.2 Ensures appropriate prescribing of medications for alcohol dependence
9. Managing Uncertainty	9.1 Addresses patient concerns about withdrawal symptoms and readiness for change
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and manages complications of chronic alcohol abuse (e.g., cirrhosis, Wernicke’s encephalopathy)

CASE FEATURES

Middle-aged male with long-term alcohol use, drinking 8–10 standard drinks daily.
Presenting with fatigue, poor sleep, hand tremors, and weight loss.
Has mild hypertension and fatty liver, with concerns about long-term health impact.
Uncertain about quitting vs. reducing alcohol intake, worried about withdrawal symptoms.
Needs assessment of alcohol dependence, complications, and treatment options.

INSTRUCTIONS

Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: David Mitchell
Age: 52
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Amlodipine 5mg daily (hypertension)

Past History

Hypertension (diagnosed 5 years ago)
Fatty liver disease (diagnosed last year, mildly elevated LFTs)
No known diabetes, liver cirrhosis, or pancreatitis

Social History

Works as a truck driver but has recently been taking time off due to fatigue
Drinks 8–10 standard drinks per day, mostly beer, for over 20 years
No history of seizures or complicated withdrawal
Smokes 10 cigarettes per day, no illicit drug use

Family History

Father had alcohol dependence and liver cirrhosis

Smoking

Current smoker, 10 cigarettes per day

Alcohol

8–10 standard drinks per day, increased over the past 10 years

Vaccination and Preventative Activities

No hepatitis B vaccination
Last GP visit was two years ago

SCENARIO

David Mitchell, a 52-year-old truck driver, presents with fatigue, poor sleep, hand tremors, and weight loss. He drinks 8–10 standard drinks per day, mainly beer, and has noticed difficulty concentrating at work.

He has mildly elevated liver enzymes and a diagnosis of fatty liver disease, but no history of withdrawal seizures or hospitalisations.

He is not sure if he wants to quit drinking completely, but is worried about withdrawal symptoms if he reduces alcohol use.

On examination, he has mild resting tremors, hypertension, and palmar erythema, but no jaundice, ascites, or stigmata of advanced liver disease.

He seeks advice on his health risks, withdrawal symptoms, and options for reducing alcohol use.

EXAMINATION FINDINGS

General Appearance: Well, slightly anxious
Vital Signs:

Temperature: 36.9°C
Heart Rate: 88 bpm
Blood Pressure: 142/88 mmHg
Respiratory Rate: 16 breaths per minute

Neurological Examination:

Mild hand tremors, no ataxia or confusion
Normal reflexes, power, and sensation

Abdominal Examination:

No hepatosplenomegaly, no ascites
Mild tenderness in the right upper quadrant

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What aspects of history and examination are critical in assessing this patient’s chronic alcohol use?

Prompt: How do you assess alcohol dependence and withdrawal risk?
Prompt: What complications of alcohol abuse need to be considered?

Q2. Based on the findings, what is your differential diagnosis, and what is your working diagnosis?

Prompt: How do you differentiate alcohol dependence from harmful alcohol use?
Prompt: What features would suggest alcohol-related liver disease?

Q3. How would you manage David’s alcohol use and withdrawal risk?

Prompt: What pharmacological and non-pharmacological strategies can be used?
Prompt: When is inpatient withdrawal management indicated?

Q4. How would you counsel David on harm reduction and long-term health risks?

Prompt: How do you discuss the risks of continued alcohol use vs. gradual reduction?
Prompt: What lifestyle and preventive measures should be addressed?

Q5. What follow-up plan would you implement?

Prompt: When should he return for review?
Prompt: When would referral to an addiction specialist or liver clinic be appropriate?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What aspects of history and examination are critical in assessing this patient’s chronic alcohol use?

A structured history and focused examination are essential to assess alcohol dependence, complications, and withdrawal risk.

1. History

Alcohol consumption:
- Quantity, frequency, duration (8–10 standard drinks/day for 20+ years).
- Patterns of drinking (binge vs. continuous).
- Attempts to reduce alcohol and withdrawal symptoms (e.g., tremors, sweating, anxiety, seizures).
Complications of chronic alcohol use:
- Liver disease: Jaundice, ascites, varices, hepatic encephalopathy.
- Neurological effects: Peripheral neuropathy, cognitive changes, Wernicke’s encephalopathy (ataxia, confusion, ophthalmoplegia).
- Psychosocial impact: Work, relationships, mental health, financial concerns.
Risk factors for severe withdrawal:
- Previous withdrawal seizures or delirium tremens (DTs).
- Co-existing mental health issues (depression, anxiety, suicidality).
- Use of other CNS depressants (benzodiazepines, opioids).
Family and social history:
- Family history of alcohol dependence or liver disease.
- Social support for reducing alcohol or seeking treatment.

2. Examination

General assessment:
- Nutritional status, muscle wasting, signs of neglect.
Vital signs:
- Hypertension, tachycardia (autonomic dysfunction), fever (infection, sepsis).
Liver examination:
- Hepatomegaly, jaundice, ascites, spider naevi, palmar erythema.
Neurological examination:
- Tremors (alcohol withdrawal), peripheral neuropathy, cognitive changes.

A structured assessment helps to differentiate harmful use from alcohol dependence and determine risk of withdrawal complications.

SUMMARY OF A COMPETENT ANSWER

Evaluates alcohol use pattern, dependence, and withdrawal risk.
Assesses complications of alcohol abuse (liver disease, neurological effects).
Identifies psychosocial impacts and readiness for change.
Conducts focused examination to detect liver dysfunction and neurological complications.

PITFALLS

Failing to assess for alcohol withdrawal risk, missing potential seizures or delirium tremens.
Overlooking signs of advanced liver disease, which may require urgent hepatology referral.
Not exploring the psychosocial impact, which influences motivation for change.
Neglecting concurrent mental health conditions, such as depression or suicidality.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

2. Clinical Information Gathering and Interpretation

2.1 Conducts a structured history to assess alcohol use, dependence, and complications.
2.3 Identifies physical and psychological sequelae of chronic alcohol abuse.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD