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Primary diagnosis Moderate Alcohol Use Disorder
Symptoms of patient MLS, 40 years old, indicate Moderate Alcohol Use Disorder. Its pathophysiology involves damage to the gastrointestinal tract, cardiovascular and nervous systems, reduced immunity. For these reasons, pharmacology for this diagnosis will include drugs that reduce alcohol craving, as well as helping to restore and balance chemicals in the brain.
Diagnostic Testing Recommended by National Guidelines and Labs
The primary tool to help determine the disease’s presence are surveys – CAGE-test, Alcohol Use Disorders Identification Test (AUDIT), usage of DSM 5 criteria, and others (Buddy, 2020). Physical examination may show signs of complications and comorbidities:
- redness on the face due to high blood pressure;
- changes in complexion due to harm to the liver;
- lack of coordination;
There are no specific laboratory tests to determine an alcohol use disorder. Still, some can help determine a relapse or chronic condition by the presence in the blood or urine of certain substances:
- Gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) indicate liver abnormalities.
- Phosphatidyl ethanol (PEth), ethyl glucuronide (EtG), and ethyl sulfate (EtS) appear as a result of the breakdown of alcohol (“Alcoholism,” 2017).
- Acamprosate (Campral®): Two pills three times a day
- Disulfiram (Antabuse®): One pill once a day
- Naltrexone (Revia®, Vivitrol®): One pill once a day
- Topiramate (Topamax®, Trokendi XR®, Qudexy XR®): One pill once a day (“Medicines,” 2016)
Detoxification is necessary to remove the withdrawal symptoms.
Psychological counseling. Therapy for alcohol addiction helps find the cause of the disease and ways to eliminate it. If a dependent person consciously understands the negative consequences of the condition and actions, he or she will be able to use the internal resources of the body and actively enter the fight for health.
Group therapy. The alcohol-dependent, who is treated in the group, understands the condition more quickly. MSL has the opportunity to evaluate behavior and know that she is not alone with this problem.
Taking medications – reduces the craving for alcohol and restores the balance of microelements.
MSL, after treatment, will need therapy to change lifestyle and adopt new patterns of behavior. It involves developing healthy habits, taking care of mental and physical health.
After completing a rehabilitation course, the patient needs constant support. Meeting with support groups or group therapy, as well as personal treatment with a psychologist, is recommended.
MSL needs referrals to
- alcohol treatment specialists for a more accurate treatment plan;
- psychotherapist for the treatment of depression and support;
- a gastroenterologist, cardiologist, and neuropathologist to check health status;
- support groups.
Agency for Healthcare Research and Quality (supported by the U.S. Department of Health & Human Services) guidelines were used to diagnose and develop a treatment plan. Also, for diagnosing mental disorders, a DSM-5 guide is needed to determine the criteria for the disease (“Diagnosis reference guide,” n.d.). Based on them, Moderate Alcohol Use Disorder was diagnosed, and treatment was also prescribed. Considering the personal approach to the client, she was also given the referrals and advice on fighting with depression. For future patients with a similar diagnosis, the same sources will be used, but other referrals will be proposed depending on the disease’s cause and its severity. Coding: 303.90 (F10.20).
Alcoholism. (2017). Lab Tests Online. Web.
Buddy, T. (2020). Alcohol screening tests ideal for healthcare settings. Verywell Mind. Web.
Diagnosis reference guide. (n.d.). Contra Costa. Web.
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Medicines to treat alcohol use disorder. (2016). Agency for Healthcare Research and Quality. Web.