Substance Abuse/Social History Case
Substance Abuse/Social History Case
Please assess the student as they take the following history.
Student's Email

CASE - The evaluating student should read the following case and role-play for their peer

 Dear Student: The following exercise is meant to be done as a role-play.  One student should read the case and role-play the patient.  The other student should act as the physician, and should not read the case or the checklist in advance. A third student, or the "patient", should complete the checklist during the interview to track their peer's progress.


Case:  Mr. SA


You are Mr. SA, a 55 year-old construction worker.  You are going to the doctor today because you have been experiencing palpitations, on and off, for the past few months.


You started noticing your racing heart about 5 months ago.  The first episode occurred early in the morning; you woke up feeling as if you had just climbed ten flights of stairs.  While you could not identify anything to make the feeling worse or better, you noticed that it went away after about 15 minutes.  You experienced no associated symptoms.   Since then, you have had these episodes frequently-sometimes up to 5 times per day-normally when you wake up in the morning or while you are at work.  About one month ago, you saw a cardiologist who, after performing an ECG and stress testing, ruled out any cardiac cause of your symptoms.  Before 5 months ago, you had never experienced anything like this before.  No one in your family has any health problems related to their heart.


You have no diagnosed medical illnesses.  You take no medications or alternative medicines.  You have never had surgery.  You have no allergies.  You have been hospitalized two times, both in the last 5 years, and both due to falls that resulted from “misadventures at the bar”.  


You smoke ½ a pack of cigarettes per day, and have been for 35 years.  You drink 10-20 drinks (whiskey, usually) per day. You are open about your alcohol consumption and admit that perhaps you should try to cut down on your drinking.  On an average day you need a few drinks to get up in the morning and will drink throughout the day as well.  You also go out to the bar with friends a few nights per week and “get wasted”.  You don’t know why your drink so much—you feel you have nothing better to do and have fallen into the habit over the last 15 years.


You live alone in a small apartment. You went to college to learn about management before entering the construction field. You are divorced with no children.  After your divorce 20 years ago you haven’t really been interested in any sort of real companionship.  You have one sister, who he sees a few times per month, but you find it a chore as she is always nagging you about your drinking.  You have some friends that you meet at the bar during the week, though you rarely do anything other than that with them.  You enjoy golfing but haven’t really had the energy to go over the last few years.


Alcohol Use Disorder:  Alcohol use disorder is a DSM-V recognized disorder that is defined based on the presence of certain criteria related behavioural, physiological, psychological, and social impact of a person’s alcohol use. For more information, see:

INTRODUCTION - The student should perform the following:

Washes hands
Introduces self to patient

IDENTIFYING DATA- The student should inquire about the following:

Name of patient
Age of patient

CHIEF CONCERN - The student should inquire about the following:

Nature of concern
Duration of concern

HISTORY OF PRESENT ILLNESS- The student should inquire about the following:

The history of presenting illness should be characterized in detail, including obtaining information about the complaint, its associated symptoms, pertinent positives/negatives, and the impact of illness on quality of life and function.  As this case focuses on substance abuse history, however, there is no detail expected beyond what is listed below:


Onset of palpitations
Alleviating factors of palpitations
Exacerbating factors of palpitations
Quality of palpitations
Severity of palpitations
Course and progression of palpitations

General Questions

Associated symptoms
Previous similar episodes (includes: investigations related to these episodes)
Impact on quality of life and work performance
Family history of heart disease

MEDICATIONS AND ALLERGIES- The student should inquire about the following:

Medications (includes: prescription, over-the-counter, and herbal/alternative medicines)
Allergies to drugs or otherwise (includes: nature of reaction, timing of reaction, formal testing performed)

PAST MEDICAL HISTORY - The student should inquire about the following:

Though it is important to ask about diagnosed medical illnesses, surgeries, hospitalizations, and immunization history, this is not relevant for this case.

SOCIAL HISTORY - The student should inquire about the following:

Living arrangement
Intimate relationships
Children & Family
Hobbies & Interests
Social support

HABITS AND SUBSTANCE USE HISTORY- The student should inquire about the following:

General Questions

Smoking (includes: pack years; if they quit, when)
Number of alcoholic drinks per week

1 standard drink=12oz/341mL beer (5% alcohol) or 5oz/142mL wine (12% alcohol) or 1.5oz/43mL spirits (40% alcohol).

Number of days per week of drinking alcohol
How many alcohol drinks on a typical day of drinking

Low risk alcohol consumption is no more than 3 standard drinks per day (and no more than 15/week) for a man, and no more than 2 standard drinks per day (and no more than 10/week) for a woman.

Max. number of alcoholic drink on a single day
Drugs (includes: types, frequency of use, quantity, methods, and prior use)

Questions Related to Substance Abuse

Reasons for using
Negative consequences of alcohol consumption (includes: blacking out, injuries, legal trouble)
Have you ever felt the need to CUT DOWN on drinking?

Part of CAGE questionnaire.

Have you ever been ANNOYED about criticism of your drinking/other drug use?

Part of CAGE questionnaire.

Have you ever felt GUILTY about your drinking or other drug use?

Part of CAGE questionnaire.

Have you ever had an EYE-OPENER (taken a drink to get going in the AM)?

Part of CAGE questionnaire.


REVIEW OF SYSTEMS - The student should inquire about the following:

Though it is important to perform a thorough review of systems, this is not relevant for this case.