NRNP 6635 Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

NRNP 6635 Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Subjective:

CC (chief complaint):

HPI:

Ally Patel is a 48-year-old female client on psychiatric evaluation. Her school’s EAP counselor referred her for psychiatric intervention following concerns about the client’s potential substance use. Ally has been late for classes for about 22 days after engaging in excessive alcohol intake. She was referred for psychiatric care to get help for her drinking behavior and retain her in school. The client states that she was late to work on the interview day because she had attended a party the previous evening and took too much alcohol. Initially, she denies that she got drunk and passed out but admits it afterward. She admits to drinking too much alcohol every night. She mostly drinks by herself, but once in a while, she goes to a bar accompanied by her friends or drinks during school functions, where they supply alcohol liberally. Furthermore, she states that she takes 5-6 glasses of wine and several mixed drinks when she has it rough with her students.

Ally attributes the excessive alcohol consumption to the stress she experiences at school caused by her students’ indiscipline. She takes too much alcohol but and it affects her differently, including passing out on several occasions when drunk. Students and parents have complained that the client has on several occasions taught while drunk, but she denies the allegations. Her students have complained that Ally goes to class drunk and instructs them to read from their textbook or copy notes from the board while sleeping with her head on the desk. The client’s drinking behavior is a threat to her job, and the Board of Education may dismiss her if she fails to cooperate with the psychiatric evaluation.

Past Psychiatric History:

• General Statement: No pertinent psychiatric history.
• Caregivers (if applicable): None
• Hospitalizations: No history of psychiatric hospitalization.
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: Ally started drinking alcohol when she was a teenager. Her alcohol intake has increased over the years. She takes 5-6 glasses of wine and mixed drinks every night to get intoxicated.

Family Psychiatric/Substance Use History: Ally’s father was an alcoholic. He got into Alcohol Anonymous, which helped to get sober.

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Psychosocial History:

The client is an only child and was raised by parents in San Francisco, CA. She has a Ph.D. in biology and a master’s degree in high school education. She is currently a high school teacher. She is currently in a relationship.

Medical History:

• Current Medications: None
• Allergies: No known food or drug allergies.

• Reproductive Hx: Para 0+0; No history of gynecologic disorders.

ROS:

• GENERAL: Denies fever, chills, weight gain/loss, or fatigue.
• HEENT: Denies blurred vision, eye pain, hearing loss, ear discharge, rhinorrhea, hoarse voice, or sore throat.
• SKIN: Denies skin rashes, itching, or bruises.
• CARDIOVASCULAR: Denies palpitations, chest pain, or SOB on exertion.
• RESPIRATORY: Denies chest pain, cough, SOB, or sputum production.
• GASTROINTESTINAL: No nausea, vomiting, abdominal pain, diarrhea/ constipation, or tarry stools.
• GENITOURINARY: Denies pelvic pain, abnormal vaginal discharge, dysuria, or abnormal urine color.
• NEUROLOGICAL: Denies headache, drowsiness, fatigue, LOC, or tingling sensations.
• MUSCULOSKELETAL: No muscle pain, joint pain or stiffness, or joint enlargement.
• HEMATOLOGIC: No bruising or history of anemia.
• LYMPHATICS: Denies lymph node enlargement.
• ENDOCRINOLOGIC: Denies excessive sweating, heat/cold intolerance, polyuria, excessive hunger, or acute thirst.

Objective:

Physical exam:

Vital signs: BP: 122/76; HR- 84; RR-20; Temp- 98.24

Ht- 5’4; Wt- 138 lbs.