"Just a couple of pints" — the real alcohol history

PLAB 2 & PRES 3 · mental health / history taking · medium · 10 minutes

Candidate brief

You are an FY2 doctor in a GP surgery. Mr Gary Thompson, 47, attends for a hypertension review. His blood pressure today is 158/96 despite amlodipine 5 mg. Recent bloods show a raised GGT of 112 (normal <50) with otherwise normal liver function. When you ask about alcohol, he says: "Just a couple of pints after work, doctor. Nothing serious." His wife telephoned the practice last week, worried about his drinking; he does not know she called. Please take an alcohol history and discuss your findings and plan.

What examiners look for

Nobody drinks "a couple of pints". Quantities in alcohol histories are compressed by shame, habit and genuine unit-blindness into summaries that can be out by a factor of five — so never ask "how much do you drink?"; ask "what did you drink yesterday?" and walk the week day by day, drink by drink, with measures shown and strengths named. Then do the arithmetic in front of the patient: the moment "a hundred units" is said aloud by the doctor and verified by the patient's own numbers, the consultation has its engine. Quantity is only half the history. Dependence is diagnosed on the other half: relief drinking in the morning, withdrawal features and their relief, tolerance, salience, loss of control, failed attempts, persistence despite harm. A 40-unit-a-week drinker without dependence features and a 40-unit-a-week drinker with them are different patients with different plans — and the screening tools (AUDIT-C → full AUDIT; SADQ in specialist settings) exist to make sure you ask all of it, every time. The advice that follows from dependence is counter-intuitive and safety-critical: do NOT tell this man to stop tomorrow. In established dependence, abrupt cessation is the dangerous option — seizures and delirium tremens carry real mortality. The skilled message is "your drinking is harming you, AND stopping suddenly could harm you faster — so we stop properly, with medical help, on a plan", which is also, not coincidentally, the message most likely to keep him engaged. And hold the collateral correctly: his wife's call is clinical gold and a confidence. Use what she told you to sharpen your questions; never spend her trust to win an argument with him. The doctor who says "your wife rang" has traded a family's safety net for one moment of leverage.

Guideline references

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