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

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

Subjective:

CC (chief complaint): “I am scared.”

HPI: Lisa Tremblay is a 33-year-old female in a detox facility. She states that she fears getting into rehab because of what other people will think about her. She fears that people will think of her as a person with an addiction. She also worries about her business, which she says is over after operating for nine months. According to Lisa, the business collapsed because of her boyfriend, Jeremy, who took money from the account. The boyfriend spent the money to pay cocaine debts, and this caused the business to lose $ 80,000. Lisa was introduced to cocaine by her boyfriend, who made her believe it was non-addictive. However, she developed a cocaine addiction. Lisa reports that she feels uneasy if she does not smoke cocaine. Smoking cocaine makes her feel good, and she usually wants to smoke more when the feeling of highness reduces. According to Lisa, she does not need help because Jeremy promised her that she would be okay, and she believes him because she loves him.

Past Psychiatric History:

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

Substance Current Use and History:

Take opiates worth about $100 daily.

Uses cannabis 1–2 times weekly.

Drinks 1/2 gallon of vodka daily. She reports drinking with her friends but states that she is in control of her alcohol consumption.

Family Psychiatric/Substance Use History:  The patient’s mother has a history of agoraphobia and benzodiazepine abuse.

The father was imprisoned due to drug abuse.

The patient’s older brother has a history of opioid use.

Psychosocial History: The patient lives with her boyfriend, Jeremy, whom she reports having a strained relationship with after he cheated on her. She has a daughter with an ex-boyfriend, and the girl lives with her friends. Lisa and her boyfriend had started a web design business, which collapsed after he withdrew money to pay cocaine debts. The patient has a legal history of arrest after being found in possession of drugs. She was sexually abused by her estranged father when she was 6-9 years old. The father was incarcerated for sexual abuse and drug charges. Lisa’s mother lives in Maine. She has not heard from her older brother for ten years. She reports sleeping 5-6 hours/day, and her appetite increases when high.

Medical History: The patient has Hepatitis C. She is considering treatment for Hep C+ but needs detox first.

• Current Medications: None
• Allergies: Allergic to Azithromycin.

• Reproductive Hx: None

ROS:

• GENERAL: Denies fever, chills, weight changes, or malaise.
• HEENT: Denies eye pain, ear pain, discharge, rhinorrhea, or sore throat.
• SKIN: Denies rashes, lesions, or discoloration.
• CARDIOVASCULAR: Denies dyspnea, edema, chest pain, or palpitations.
• RESPIRATORY: Denies wheezing, cough, SOB, or sputum.
• GASTROINTESTINAL: Positive for reduced appetite. Denies abdominal pain or bowel changes.
• GENITOURINARY: Denies dysuria or abnormal PV discharge.
• NEUROLOGICAL: Denies dizziness, paralysis, or tingling sensations.
• MUSCULOSKELETAL: Denies muscle/joint pain or limitations in movement.
• HEMATOLOGIC: Denies bruising or bleeding.
• LYMPHATICS: Denies lymph node swelling.
• ENDOCRINOLOGIC: Denies excessive sweating, increased hunger, acute thirst, or polyuria.

Objective:

Physical exam: if applicable

Vital signs: BP-180/110; T- 100.0; P- 108; R-20; Ht- 5’6; Wt-146lbs

Diagnostic results:

ALT-168

AST-200

ALK-250

Bilirubin-2.5

Albumin-3.0;

GGT-59

Urine drug test positive for opiates, THC, and alcohol

BAL-308

Assessment:

Mental Status Examination:

The patient appears nervous and constantly fidgets and looks out through the window. She is alert and oriented to person, place, and time. Her self-reported mood is ‘worried,’ and her affect is broad. She has clear and coherent speech. Her thought process is coherent and goal-oriented. She exhibits n