Mr. Smith Case Study

Mr. Smith Case Study

Mr. Smith Case Study 150 150 Peter

Mr. Smith Case Study

Mr. Smith is a 65-year-old male that is accompanied by his wife to your clinic. He is following up after an ER visit for a fall at home that resulted in 6 stitches to his forehead. He admits that he had a few drinks that night before tripping over his dog. His wife adds that he has ‘a few drinks’ every night.
How will you proceed with Mr. Smith? What diagnostics will you perform? What will potentially be part of your treatment plan?

Sample Paper

How will you proceed with Mr. Smith?

Mr. Smith presents in the clinic for follow-up after an ER visit for a fall at home. The fall resulted in 6 stitches to his forehead. The patient admits to having a few alcoholic drinks before tripping over his dog. However, his wife states that he has a few drinks every night. Based on this subjective data, it is likely that Mr. Smith’s fall resulted from alcohol intoxication.

Therefore, it is essential to assess Mr. Smith for alcohol abuse disorder. The provider should ask the patient a few questions about his drinking habit during history taking. In addition, the provider should ask Mr. Smith for permission to speak to his wife regarding his drinking habit and history. Physical exam should also be conducted to assess for physical signs that indicate complications of alcohol use.

Diagnostic Tests

The diagnostics that will be performed to assess for alcohol use disorder include

a blood test to evaluate for complications of alcohol use and blood alcohol levels. A gamma-glutamyl transferase (GGT) test will be essential to assess organ damage (liver and bile duct) resulting from alcoholism. The amount of GGT enzyme in the blood increases when the liver or the bile duct is damaged. In addition, a psychological evaluation will be performed to assess the impact of alcohol on the patients’ thoughts, feelings, and behavior patterns. The DSM-5 criteria for alcohol use disorder will be used to confirm the diagnosis (Coriale et al., 2018).

Treatment Plan

The alcohol abuse disorder will focus on helping the patient learn ways to control the disease. The treatment will help the patient abstain from alcohol and manage withdrawal effects. For best results, the treatment plan will entail medicines and behavioral therapies (Witkiewitz, Litten & Leggio, 2019). The patient will be prescribed disulfiram to help prevent him from drinking alcohol. The drug works by making the patient feel sick after consuming alcohol. Naltrexone will also be prescribed to reduce alcohol craving (Kranzler & Soyka, 2018). Cognitive-behavioral therapy and psychological counseling will be offered to help the patient to understand his problem with alcohol better. The support group will help the recovery process by helping the patient cope with the psychological aspects of alcohol use (Winslow, Onysko & Hebert, 2016).



Coriale, G., Fiorentino, D., Porrari, R., Battagliese, G., Capriglione, I., Cereatti, F., … & Ceccanti, M. (2018). Diagnosis of alcohol use disorder from a psychological point of view. Rivista di psichiatria53(3), 128-140.

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. Jama320(8), 815-824. doi:10.1001/jama.2018.11406

Winslow, B. T., Onysko, M., & Hebert, M. (2019). Medications for alcohol use disorder. American family physician93(6), 457-465.

Witkiewitz, K., Litten, R. Z., & Leggio, L. (2019). Advances in the science and treatment of alcohol use disorder. Science advances5(9), eaax4043.