NUR 676 Module 4 SOAP Note Example

SOAP Note: Alcohol Use Disorder Identified Through Screening in a 52-Year-Old Man

[Student Name]

Southern New Hampshire University

NUR 676: Primary Care for Mental Health

Module Four SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

SOAP Note: Alcohol Use Disorder Identified Through Screening in a 52-Year-Old Man

Unhealthy alcohol use is common among primary care patients and often hidden behind hypertension, reflux, insomnia or abnormal liver tests. Patients rarely raise it, and clinicians who do not ask miss both the problem and a chance to help. Brief screening followed by a short counseling conversation, and medication when alcohol use disorder is present, can be delivered in a primary care visit. Robert, 52, came to a composite community clinic for a blood pressure check, and his screening score prompted a closer look. This SOAP note documents the assessment and plan. It argues that a positive screen should lead to confirmation of the diagnosis, assessment of withdrawal risk and complications, a respectful brief intervention and evidence-based medication, rather than a quick warning to cut back.

Subjective

Chief concern: blood pressure follow-up.

History of present illness: Robert's blood pressure has been above goal for six months despite lisinopril. On the routine AUDIT-C, he reported drinking four or more times a week, typically five or six beers a night, and more than six drinks on one occasion weekly. When asked more about it, he said his drinking increased after he was laid off two years ago, that he usually drinks more than he plans to, that he has tried to cut back twice without success, that he needs more beer than before to feel relaxed and that his wife has complained about it. He has never had a seizure, hallucinations or delirium when stopping but gets shaky and sweaty on mornings after a night without drinking. He denies other drugs, drinking and driving and thoughts of self-harm. His mood is somewhat low, and he sleeps poorly.

Past history: hypertension. Medications: lisinopril 20 mg daily. No opioid use. Family history: father with alcohol use disorder.

Objective

Blood pressure 152/94, pulse 90. No tremor at rest, no jaundice or stigmata of chronic liver disease. AUDIT-C score 9 of 12. Laboratory tests from last week: aspartate aminotransferase 78 U/L, alanine aminotransferase 42 U/L, gamma-glutamyl transferase 120 U/L, mean corpuscular volume 101 fL, normal bilirubin, albumin and platelets. PHQ-9 score 8.

Assessment

1. Alcohol use disorder, moderate. Bush et al. (1998) developed the AUDIT-C, the first three consumption questions of the Alcohol Use Disorders Identification Test, and showed in a sample of male veterans that the short version held up nearly as well as the full ten-item test in identifying heavy drinking and alcohol use disorders. Robert's score of 9 is well above commonly used cutoffs. The interview confirmed five criteria: drinking beyond what he planned, two failed attempts to reduce, needing more for the same effect, withdrawal symptoms and continued use despite relationship problems, which indicates moderate disorder. His elevated aspartate aminotransferase to alanine aminotransferase ratio, raised gamma-glutamyl transferase and macrocytosis are consistent with heavy drinking.

2. Uncontrolled hypertension, likely worsened by alcohol.

3. Mild depressive symptoms, possibly related to drinking and job loss; to be reassessed after drinking decreases.

4. Risk of withdrawal. Morning shakiness and sweating indicate physiological dependence. He has never had a withdrawal seizure or delirium, which lowers his risk, but he should not stop abruptly without a plan.

Brief Intervention

Primary care clinicians are advised by the USPSTF to ask every adult about drinking and, when the answers show risky use, to follow with a short counseling conversation aimed at cutting back (Curry et al., 2018). The conversation with Robert followed that approach. He was given his score and told plainly what it meant, asked what he thought about his drinking and how it related to his blood pressure and mood and asked what he wanted to change. He said he was worried about his liver and his marriage and wanted to cut down, perhaps to stop. Together they set a two-week goal of two drinks at most on any given day, with at least three alcohol-free days, and discussed strategies: not keeping beer in the house, telling his wife his goal and replacing his evening routine with a walk.

Medication

Jonas et al. (2014) pooled trials of medications for adults with alcohol use disorder in outpatient settings and found that both acamprosate and oral naltrexone at 50 mg daily reduced return to drinking, with naltrexone also reducing return to heavy drinking. Numbers needed to treat were in a range comparable to many accepted medications, yet these drugs are rarely prescribed. Because Robert uses no opioids and his liver enzymes, though raised, remain well under triple the normal ceiling, naltrexone 50 mg daily was started after discussing its main side effects, nausea and headache, and the need to carry a card noting that he takes it in case he ever needs pain treatment. Liver tests will be repeated in one month.

Plan and Follow-Up

Thiamine 100 mg daily. Because he plans to cut down gradually rather than stop suddenly, and has no history of complicated withdrawal, outpatient management is appropriate; he was told to call immediately for tremor, confusion, hallucinations or seizures and not to stop drinking abruptly without talking to the clinic. Counseling with the in-house therapist was arranged, and information about mutual help groups were provided. Hepatitis B and C screening was ordered. A repeat pressure reading is booked for two weeks out, by which time drinking less may already be helping. Follow-up in two weeks to review drinking against the goal, side effects and blood pressure, with the AUDIT-C and PHQ-9 repeated at one month.

Involving His Family and Addressing Stigma

Robert said he was embarrassed to talk about his drinking and worried that it would appear in his record where his employer could see it. He was told that his health information is confidential and that alcohol use disorder is a medical condition, not a moral failing, with effective treatments like those for his blood pressure. With his permission, his wife was invited to the next visit so she could understand the plan and how to support his goal without monitoring him in ways that cause conflict. He was also offered the option of an online recovery group that meets in the evening, since he felt uncomfortable about attending an in-person meeting in his small town. Addressing shame and privacy directly makes it more likely that he will return for follow-up and be honest about how the plan is going.

Conclusion

A routine three-question screen revealed moderate alcohol use disorder behind Robert's uncontrolled blood pressure and abnormal liver tests. Confirming the diagnosis, assessing withdrawal risk, delivering a respectful brief intervention as the USPSTF recommends and starting naltrexone supported by meta-analysis evidence give him a realistic plan, with follow-up that will show whether his drinking, blood pressure and mood improve together.

References

Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789-1795. https://doi.org/10.1001/archinte.158.16.1789

Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., Doubeni, C. A., Epling, J. W., Kemper, A. R., Kubik, M., Landefeld, C. S., Mangione, C. M., Silverstein, M., Simon, M. A., Tseng, C. W., & Wong, J. B. (2018). Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA, 320(18), 1899-1909. https://doi.org/10.1001/jama.2018.16789

Jonas, D. E., Amick, H. R., Feltner, C., Bobashev, G., Thomas, K., Wines, R., Kim, M. M., Shanahan, E., Gass, C. E., Rowe, C. J., & Garbutt, J. C. (2014). Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis. JAMA, 311(18), 1889-1900. https://doi.org/10.1001/jama.2014.3628