Subjective
Ally Chen, a client from the case study 114-2 by Symptom Media, claimed that the students had forced her into drinking to overcome the stressful work environment. She claimed that students are not respectful and that the school does not support teachers. She also stated that her father was an alcoholic, which caused her to grow up in an alcoholic environment.
Ally Chen has been drinking for the past 23 years, and she had a DUI at the age of 21. Alcohol addiction has harmed her work life to the extent that she rarely changes her clothes and checks student papers under the influence. She stated that she had missed class for 22 days.
CC (Chief Complaint): Chronic Alcoholism.
HPI: According to the case study, Ally Chen had a DUI (driving under the influence) at the age of 21 and has been drinking ever since, until now, when she was 44 years old.
Past Psychiatric History
- General Statement: The patient has not had any previous psychiatric assessment. This is her first meeting with a psychiatrist.
- Caregivers (if applicable): Lives alone, no caregiver assigned.
- Hospitalizations: None.
- Medication trials: None.
- Psychotherapy or Previous Psychiatric Diagnosis: None.
Substance Current Use and History
Ally Chen has a history of drinking that has lasted more than twenty years. She had a DUI at the age of 21, and claims that she has been forced into drinking by the stressful work environment. Addiction to drinking has affected her work life to the extent that she hardly changes her clothes, marks student papers when intoxicated, and misses work for more than twenty days. She stated that she had missed class for 22 days.
Family Psychiatric/Substance Use History
According to the case study by Symptom Media (2018), Ally’s father was an alcoholic, even though their mother hated alcohol.
Psychosocial History
Ally Chen is sociable; she is the only child in the family. She frequently goes out to drink with friends and can drink to the extent of passing out. During the recent school hosting event, she was drunk and was not able to leave the classroom. Ally Chen takes 5-6 glasses of wine with a couple of mixed drinks. She currently lives alone; she is divorced with one child who lives with the father (Symptom Media, 2018).
Medical History
Denies having a previous diagnosis of any medical condition.
- Current Medications: The client is not currently taking any medications.
- Allergies: No allergies recorded at the moment.
- Reproductive Hx: No reproductive problems and is a mother of one.
ROS
- GENERAL: The client does not appear alert, cannot remember a lot of information, only knows that the school had a party last night, is weak, and has ongoing weight loss.
- HEENT: No lesions and lumps, hair is evenly distributed, eyebrows are full and evenly distributed, nose is midline with a scar on the right, eyelids are within the normal range, eyelashes are full and evenly distributed, the pupil is reactive to light, and it is within the normal size. No lumps on the ears, well-positioned, and the pinna within position. There is decreased hearing, and the client has to repeat a word before they can hear it. One tooth missing, colored teeth, cracked and dry lips, gums discolored and swollen. Throat not swollen, no tonsils.
- SKIN: Skin is pale, inflamed, with acne.
- CARDIOVASCULAR: Palpitations and hypertension.
- RESPIRATORY: Awheezing sound is heard when the client breathes in and out. She says that some pain fades with time.
- GASTROINTESTINAL: Impaired stomach lining, blood in stool.
- GENITOURINARY: Frequent urination, almost three times within an hour, pain when passing urine, andburning sensation.
- NEUROLOGICAL: Alert, maintains eye contact, hasclear vision, and responds to sound and touch.
- MUSCULOSKELETAL: Pain in the joints when walking, low back pain.
- HEMATOLOGIC: Abnormal blood cells.
- LYMPHATICS: Swollen lymph nodes in the neck.
- ENDOCRINOLOGIC: Normal endocrine glands.
Objective
The client was suffering from chronic alcoholism. Alcoholic addiction had caused the client to develop physical injuries on the body, including an inability to concentrate on work.
Physical exam: The patient appeared stressed and irritable and was experiencing constant mood swings. The patient appeared tired and dizzy, unwilling to maintain eye contact, and expressed reduced self-care. Appeared tired, seemed not to have eaten for the past 24 hours.
Diagnostic results: Alcohol use disorder.
Assessment
Mental Status Examination
The patient appeared disturbed and worried, with frequent mood swings that could be attributed to persistent concerns. She was also unable to pay attention to the discussion and was giving excuses for her frequent drinking behavior. The patient did not experience any difficulty growing up. She grew up in a family with an alcoholic father, even though the mother was strict at home (Symptom Media, 2018). The patient appears to have impaired cognition as she thinks before responding to questions. She became nervous when she realized that it was the school that had just told her to see the counselor.
Differential Diagnoses
The three possible differential diagnoses include alcohol use disorder, substance abuse disorder, and psychotic disorder.
Alcohol Use Disorder
The patient is more likely to suffer from Alcohol Use Disorder, given the indication of dependence on alcohol to solve emotional problems. According to Carvalho et al. (2019), Alcohol Use Disorder is characterized by repeated alcohol consumption, accompanied by health and safety issues and legal consequences. According to the case study by Symptom Media (2018), Ally Chen has had legal issues associated with alcohol dependency, including DUI and missing class for 22 days. She now risks losing her teaching job.
Substance Abuse Disorder
The second differential diagnosis is substance use disorder. Melchior et al. (2019) defined substance use disorder as a disease that affects a person’s brain, leading to the inability or lack of control over the use of legal or illegal drugs and medicines. Ally Chen exhibits some symptoms of substance use disorder, such as withdrawal symptoms, lack of coordination, and dependence on alcohol to keep stress away.
Psychotic Disorder
The third differential diagnosis is a psychotic disorder. Matsuzaka & Knapp (2020) explained that a psychotic disorder causes an individual to be disconnected from reality. Individuals may also experience hallucinations, anger, and mood swings that affect a person’s social life. Despite the signs and symptoms presented, both psychosis and substance use disorders do not meet DSM-5 criteria as the primary diagnosis.
Throughout this analysis, it is evident that Alcohol Use Disorder stands out as the primary diagnosis. The patient was diagnosed at a tender age and confessed to having been drinking to keep stress away. Additionally, the patient has excuses for drinking, including blaming students and the school administration for having contributed to her drinking behavior.
Reflections
I believe that there are significant changes that I could have introduced to the interview to get more information from the patient. One of the factors I could have considered is to take into consideration the aspect of culture and its impact on the patient’s alcohol abuse history. I could have asked questions that could have helped connect to the history of the patients and socio-cultural factors that could have contributed to the patient’s current status. Matsuzaka & Knapp (2020) explained that a cultural approach in interviewing patients with alcohol and substance use can reveal the hopes and expectations that one has in life. In this case, it becomes possible to connect the patient to the social support networks that could help alleviate Alcohol use disorder.
References
Carvalho, A. F., Heilig, M., Perez, A., Probst, C., & Rehm, J. (2019). Alcohol use disorders. The Lancet, 394(10200), 781-792. Web.
Matsuzaka, S., & Knapp, M. (2020). Anti-racism and substance use treatment: Addiction does not discriminate, but do we?. Journal of Ethnicity In Substance Abuse, 19(4), 567-593. Web.
Melchior, H., Hüsing, P., Grundmann, J., Lotzin, A., Hiller, P., Pan, Y.,… & Cansas Study Group. (2019). Substance abuse-related self-stigma in women with substance use disorder and comorbid posttraumatic stress disorder. European Addiction Research, 25(1), 20-29. Web.
Symptom Media. (Producer). (2018). Training title 114-2 [Video]. Web.