Complete Shadow Health Alcohol Use Assessment for William Jefferson. CAGE score 3/4, AUDIT-C elevated — moderate alcohol use disorder. Liver assessment (hepatomegaly noted), withdrawal risk evaluation using CIWA-Ar, psychosocial impact assessment and motivational interviewing documentation. Used in Walden, Capella and GCU health assessment courses.
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William Jefferson presents for a routine health assessment. He initially downplays his drinking but during the structured assessment reveals consuming 6-8 drinks daily, including in the morning to avoid feeling shaky. His CAGE score is 3/4 — positive for feeling the need to Cut down, feeling Annoyed by criticism, and needing an Eye-opener in the morning. He denies feeling Guilty about his drinking.
The Alcohol Use Assessment covers the complete alcohol history using CAGE and AUDIT-C screening tools, withdrawal symptom screening using CIWA-Ar criteria, liver assessment (hepatomegaly on palpation, spider angiomata noted on skin), nutritional assessment and psychosocial impact evaluation including job and family impacts.
CAGE: 3/4. AUDIT-C: elevated. Hepatomegaly on palpation. Diagnosis: Alcohol use disorder, moderate severity. CIWA-Ar monitoring, thiamine supplementation, addiction medicine referral and withdrawal management plan documented.