Episode 24: Alcohol in Clinic[Music to start: Grieg’s Morning Mood (https://www.youtube.com/watch?v=-rh8gMvzPw0) The sun rises over the San Joaquin Valley, California, today is August 21, 2020. Fresh from the oven! The USPSTF issued the following recommendation on August 18, 2020: All sexually active adolescents and adults at increased risk should receive behavioral counseling to prevent Sexually Transmitted Infections (STIs).Counseling results in a moderate net benefit in prevention of STIs, a Grade B recommendation, which means the benefit is moderate to substantial, so offer this service to your patients.Some examples of patients who can benefit from counseling are those who have a current STI, do not use condoms, have multiple partners, belong to a sexual and gender minority, HIV patients, IV drug users, persons in correctional facilities, and others.Offering counseling in person for 30 minutes or less in a single session may be effective, but the strongest effect was found in group counseling for more than 120 minutes, delivered in several sessions. Other options include referring patients for counseling services or inform them about media-based interventions. Of note, there are about 20 million new STIs every year in the US (1). [Music mixes with country Chris Haugen - Cattleshire - Country & Folk https://www.youtube.com/watch?v=WiYqHkH4Tnc&list=PLYo1YtVKirP-LAZ3AjpIiJNW9KIe1MJLw&index=7]Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] ____________________________[MUSIC][Quote]“The illiterate of the 21st century will not be those who cannot read and write but those who cannot learn, unlearn, and relearn” –Alvin Toffler.Sometimes there are things we need to unlearn. We see that frequently in Medicine. New guidelines, recommendations, tests, and treatments are updated regularly. We need to make sure we never stop learning, unlearning and relearning; and residency is just part of the beginning of a life-long commitment to learn. Today we have a dynamic intern. She started just one month ago her residency. I’m happy to welcome Ariana Lundquist today.     Question number 1: Who are you?Hi, my name is Ariana and I am a first-year resident at Rio Bravo Family Medicine Residency.  I am a California girl through and through from Orange County, California.I grew up surfing every weekend with my dad who also is a family physician.Early on I knew I wanted to be a doctor because I really loved being at my father's private practice. My mom had her private practice at my father's clinic, and so every day after school she would pick my sister and I up and take us to clinic.  We would run around and interact with every patient.  We truly grew up in the clinic and I cherish those memories as an adult.   I went to Canyon high school where I did water polo and swim.  For undergrad, I went to Cal State Long Beach where I majored in cell molecular biology with a minor in general chemistry and surfing.  I then went to the beautiful island of Dominica to attend medical school at Ross University.   My last 2 years of medical school were spent in Bakersfield.  As someone who loves the heat and sweet hospitality, Bakersfield was really fit for me.  I truly am excited to learn and grow as a physician here in Bakersfield with the Rio Bravo family medicine team.   For fun, I still try to surf whenever I get a chance, free dive, scuba dive, karaoke, and spend time with my family. Question number 2: What did you learn this week?This week I was working on my quality improvement project with my co-resident Dr. Civelli on alcohol withdrawals in a hospital setting.  During the research, I was wondering about how you would treat alcohol withdrawals in a clinic setting.  We encounter a lot of patients who, when they are willing to open up about it, admit to having alcohol dependency.   It is never a simple subject to talk about with patients because most people either feel that they have their alcoholism under control or that they are ashamed by the amount that they drink.  Once the patient is honest with you about the amount they drink and you realize that they are above the recommended daily intake, that is when you start to assess their willingness to quit.  That alone is another subject for a pod cast in the future, but if someone is willing to quit you have to consider if that patient is somebody who might have withdrawal symptoms.           Timing of alcohol withdrawal syndromesSyndrome Clinical findings Onset after last drink Minor withdrawalTremulousness, mild anxiety, headache, diaphoresis, palpitations, anorexia, gastrointestinal upset; normal mental status6 to 36 hoursSeizuresSingle or brief flurry of generalized tonic-clonic seizures, short postictal period; status epilepticus rare6 to 48 hoursAlcoholic hallucinosisVisual, auditory, and/or tactile hallucinations with intact orientation and normal vital signs12 to 48 hoursDelirium tremensDelirium, agitation, tachycardia, hypertension, fever, diaphoresis48 to 96 hours  Patient assessment 1) Substance use history questions include:-Duration of disorder?-When was your last drink?-How many drinks per day, and days per week?-History of withdrawal seizure or delirium tremens-Medical complications related to alcohol-Number of prior supervised withdrawal episodes?   2) General Physical Exam w/ vitals 3) Labs: CBC w/diff, blood glucose, electrolytes, calcium, magnesium, phosphorous, anion gap, renal and hepatic function 4) Withdrawal Symptoms  Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA): There are 10 areas to examine in this scale. Evaluate each area and assign a score (see details below):1. NAUSEA AND VOMITING: Ask "Do you feel sick to your stomach? Have you vomited?" Observation. 2. TACTILE DISTURBANCES: Ask "Do you have any itching, pins and needles sensations, burning sensations, numbness, or the feeling of bugs crawling on or under your skin?" Observation.3. TREMOR: Arms extended and fingers spread apart. Observation. 4. AUDITORY DISTURBANCES: Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation. 5. Paroxysmal sweats. Observation. 6. VISUAL DISTURBANCES: Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation. 7. ANXIETY: Ask "Do you feel nervous?" Observation. 8. HEADACHE, FULLNESS IN HEAD: Ask "Does your head feel different? Does it feel as if there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 9. AGITATION: Observation. 10. ORIENTATION AND CLOUDING OF SENSORIUM: Ask "What day is this? Where are you? Who am I?" Count forward by three. Interpretation of CIWA score0 to 9 points:Very mild withdrawalOutpatient management10 to 15 points:Mild withdrawal 16 to 20 points:Modest withdrawalInpatient management21 to 67 points:Severe withdrawal    5) Co-morbidities  If patient shows no symptoms in first 24 hours and they are not at risk for major withdrawal, no medication is indicated as symptoms are unlikely to develop.Ambulatory Criteria:•A patient with mild symptoms of alcohol withdrawal (CIWA-Ar

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