Table of Contents
- Subjective: Drug Addict
- CC (chief complaint): Hepatitis C treatment
- HPI: Lisa is at a detox center in Naples, FL, contemplating long-term recovery. She is considering getting Hepatitis C treatment, but first, she must be clean. Lisa had been misusing opiates for about $100 each day. She admits to using cannabis 1-2 times a week while waiting for a medical card and drinking 1/2 gallon of vodka every day (Tomasi, 2020). She had a prior arrest for drug paraphernalia possession. Her admission blood results were abnormal for ALT 168, AST 200, ALK 250, bilirubin 2.5, albumin 3.0, GGT 59, and UDS positive for opiates and THC. She tested positive for either alcohol or other substances.
- BAL was 308; all other labs were within normal levels. She recounts sexual assault as a kid between the ages of six and nine, with the culprit being her dad, who was imprisoned for the abuse and drug charges. She has a strained relationship with him. Her mother resides in Maine, suffering from agoraphobia and benzodiazepine addiction. The elder brother has had no communication with his family in the previous ten years because of opioid usage. Lisa sleeps five to six hours daily, has a diminished appetite, and chooses to get high rather than eat. She is allergic to azithromycin.
- Past Psychiatric History: Lisa and her boyfriend, Jeremy, perform commercials for local businesses. Their enterprise builds websites where they smoke opiates frequently until they have become addicted.
- General Statement: Both Lisa and Jeremy are addicts and need help being admitted into rehabilitation.
- Caregivers: Husband
- Hospitalizations: No previous hospitalization
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: even though Lisa feels she needs help at some point. She somehow trusts Jeremy’s allegation that she is fine.
- Substance Current Use and History: She is addicted to crack cocaine as she drinks half a gallon of vodka every day
- Family Psychiatric/Substance Use History: No details
- Psychosocial History: Depressive symptoms, and she always wants to be high on crack cocaine
- Medical History: None
- Current Medications:
- Allergies: No known allergies
- Reproductive Hx: No known hormone abnormalities
- ROS:
- GENERAL: There have been no fevers, but there are noticeable weight changes as the impact of drug abuse starts to show
- HEENT: Little if any headaches or nausea, no changes in vision or discomfort in the eyes, ears have minimal tinnitus or hearing changes, there is no epistaxis, irritation, or rhinitis in the nose, no mouth sores, vomiting, dry mouth, or difficulty breathing in the mouth or throat.
- SKIN: There is no family history of diabetes or hypothyroidism. There is no evidence of cold or heat sensitivity or skin or hair changes (Kranzler & Soyka, 2018). There was no polydipsia or excessive urination.
- CARDIOVASCULAR: There are no palpitations, chest discomfort, or edema.
- RESPIRATORY: There is no orthopnea, dyspnea, wheezing, or coughing.
- GASTROINTESTINAL: Pain in the abdomen, mild diarrhea, and constipation
- GENITOURINARY: No pain
- NEUROLOGICAL: Has muscular weakness and a minor loss of eyesight
- MUSCULOSKELETAL: There is muscle soreness from marijuana, stiffness, or a burning feeling.
- HEMATOLOGIC: Has an unaccounted-for weight loss
- LYMPHATICS: Swelling of a portion of the leg, that include the toes, as well as a sense of heaviness
- ENDOCRINOLOGIC: There is no family history of diabetes or hypothyroidism. There is no record of warmth, cold sensitivity, or hair or skin changes. There was no polydipsia or excessive urination.
- Physical exam:
- HEENT: Normocephalic, incisional head. The mucous membrane is dry but free of lesions.
- The neck is flexible, with no anterior lymphadenitis, thyromegaly, or thyroid tumors.
- Cardiovascular system: S1S2, no palpitations, RRR ,no gallops. There is no lumbar edema.
- Lungs: Breath sounds and the lungs are clear. There are no wheezes, petechial, or crackles.
- There are no wheezes, petechial, or crackles.
- No cyanosis on the skin. There are no sores or rashes.
- Diagnostic results:
- Assessment: Axis I- Persistent major depression without psychotic symptoms
- None for Axis II.
- None for Axis III.
- Axis IV- Recently ended a relationship with substantial other
- Assessment: Axis I- Persistent major depression without psychotic symptoms
- The primary caregiver (mother) is unemployed and temporarily outside of town.
- Score on Axis V- Assessment Analysis of Function: 15-20
- Mental Status Examination: Lisa appears clad in a dressing gown. Face expressions are few and mostly flat. She looks to have a limited choice of emotional expressiveness.
- Mood: She describes herself as emotional and low” much of the time recently. The mood is consistently low, and it is worst in the mornings.
- Affect: Primarily sad, which is consistent with the reported mood. Lisa does grin at random while discussing the bond with her daughter, who lies in another state with a friend.
- Speech: The tone and loudness are adequate. However, the pace is slowed at points. Fluent, well-organized, and clear
- Thinking Content: She is of obsessions with cocaine. She says it hits differently and makes her feel better every time she takes it (Symptom Media, 2017). However, she does not want to admit that she is an addict. Meanderings, indecision, and fears are not present in her thoughts as she is undecided about whether to seek help in a rehabilitation center or not. There are no depersonalization ideas, emotions of persecution, or physical preoccupations.
- Differential Diagnoses: Not yet
- Memory- She indicates that she is done with Jeremy being her boyfriend but admits after some time that they are back together. She remembers Jeremy having an affair with Alisa, although she has already forgiven him several times.
- Language- She can remember several instances in the past, such as her daughter, but the father is not Jeremy.
- Insight- She has been able to discuss her present circumstance even though she is yet to decide whether she needs help or not.
Summary
The patient is a 33-year-old lady in a facility contemplating admission into a rehabilitation center. Her current stresses include financial difficulties because her boyfriend spends much of their money on their business (Kranzler & Soyka, 2018). She is on and off in their relationship with Jeremy partly because of business and being a cocaine addict. She has no further plans for suicide.
Reflections
- The patient will undergo inpatient care to solve the challenges of cocaine addiction in a clean rehabilitation center.
- The following labs will be drawn: CBC, and electrolyte
- She will receive cognitive behavioral therapy to assist her in understanding addiction and changing her ideas and behavior. It will be done in a group or one-on-one with a qualified drug therapist.
- Couples counseling is also recommended so that they can work with Jeremy to solve the cocaine problem.
- The patient will engage with a care manager to discuss outpatient and inpatient treatment coordination.
References
Kranzler, H., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. Jama, 320(8), 815-824.
Symptom Media. (Producer). (2017). Training title 82 [Video].
Tomasi, D. (2020). Mind-body medicine in inpatient psychiatry. Ibidem-Verlag.