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Subjective:
CC (chief complaint): Scared of going to rehab.
HPI: L. T., a 33-year-old female patient admitted to a detox facility in Naples, FL, wants to discuss the possibility of going to a rehabilitation center.
Past Psychiatric History:
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General Statement: Alert, oriented in time and space, reluctant to communicate.
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Caregivers (if applicable): N/A
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Hospitalizations: This was the first hospitalization for detox.
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Medication trials: N/A
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Psychotherapy or Previous Psychiatric Diagnosis: Opioid and alcohol use.
Substance Current Use and History: Frequent cocaine use, cannabis 1-2 times weekly, daily intake of almost two liters of vodka.
Family Psychiatric/Substance Use History: Father illicit drug abuse, mother benzodiazepine abuse, brother opioid use.
Psychosocial History: L. has a history of drug paraphernalia possession arrest.
Medical History:
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Current Medications: N/A
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Allergies: Azithromycin
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Reproductive Hx: N/A
ROS:
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GENERAL: Decreased appetite, no recent weight changes.
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HEENT: N/A
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SKIN: N/A
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CARDIOVASCULAR: Tachycardic
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RESPIRATORY: N/A
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GASTROINTESTINAL: Decreased appetite.
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GENITOURINARY: N/A
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NEUROLOGICAL: N/A
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MUSCULOSKELETAL: N/A
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HEMATOLOGIC: N/A
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LYMPHATICS: N/A
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ENDOCRINOLOGIC: N/A
Objective:
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Physical exam: Temperature 100.0, pulse 108, respiratory rate 20, blood pressure 180/110, height 56, weight 146 lbs.
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Diagnostic results: LT 168, AST 200, ALT 250; bilirubin 2.5, albumin 3.0; GGT 59; UDS positive for THC, alcohol, and other drugs. BAL 0.308; other labs within normal ranges.
Assessment:
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Mental Status Examination: The patient is oriented in time in place, but her attention is vigilant since she is hyperresponsive to external reminders of her addiction and the fear of going to the rehabilitation center. At the same time, L. realizes that she may need professional help to overcome her addiction. She denies having hallucinations, but she lacks objectivity about her relationships with her partner Jeremy who had affairs, stole money from her, and caused her cocaine addiction. The latter resulted in L.s decreased appetite since she prefers to get high instead of eating, but the patient does not seem concerned about her weight or appearance. She does not seem to lack an accurate perception of various events and her habits. However, the patient does not want to act differently or is scared of change since she continues her relationship with an unfaithful boyfriend and claims she does not want to go to rehab.
Differential Diagnoses:
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Substance use disorder: Opiates addiction.
The patient was admitted for detoxification from opiates and alcohol. She has a long history of illicit drug use since she was exposed to such an environment in childhood because everyone in her household was addicted to some drug. Furthermore, L. reports being sexually abused by her father at the age of 6-9. Research shows that children exposed to abuse or other traumatic experiences are more likely to develop drug addiction (Somer, 2019). According to Somer (2019), one of the survivors of rape developed post-traumatic stress disorder (PTSD) and benzodiazepine addiction since alcohol and cannabis did not alleviate her symptoms. Similarly, L. has become addicted to various substances because of childhood sexual abuse. However, the patient does not admit to having any symptoms of PTSD. Still, that traumatic experience as a child caused her to develop an insecure attachment model of behavior, impulsivity, and extreme addiction to various mind-altering substances. L. abuses marihuana and cocaine since she feels an increased need to continue using these drugs, making her spend $100 a day on drugs; hence, the primary diagnosis is drug use disorder.
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Substance use disorder: Alcohol abuse.
Because the patient drinks half a gallon of vodka daily but claims that she is not addicted to it, the problem of alcohol abuse is present. The diagnostic evaluation of L.s blood and urine showed that her alcohol use is chronic since her liver enzymes are elevated, and alcohol is found in her urine, in addition to different drugs. Furthermore, when the patient was offered a glass of water, she immediately assumed that the therapist pointed to her alcohol dependency. According to Carvalho et al. (2019), alcohol use disorder are characterized by loss of control over alcohol intake, compulsive alcohol use, and a negative emotional state when not drinking (p. 781). Although L. claims she does not have a problem with alcohol consumption, it is apparent that she has a chronic issue based on her lab results. However, it is still necessary to use additional screening tools like CAGE to establish the diagnosis of alcohol use disorder since she never reported alcohol being an eye-opener for her, which is a pertinent negative.
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Major depressive disorder.
The patients mood and attitude during the interview suggest she may be depressed. The pertinent positive is that she consumes much alcohol and reports feeling betrayed by her boyfriend. Indeed, major depression is relatively common among people who abuse alcohol (McHugh & Weiss, 2019). Furthermore, it seems that she sleeps less that recommended for an average person, has a decreased appetite, and appears irritated. However, the pertinent negatives for not diagnosing clinical depression are lack of insomnia or hypersomnia, no weight fluctuations, and the absence of feeling worthless, guilty, or suicidal. Therefore, this diagnosis can be excluded from consideration unless additional information is revealed.
Reflections:Â If I were to interview this patient, I would add more questions and screening tools. I would use the CAGE tool to screen L. if she is addicted to alcohol use since she does not admit the problem despite its chronicity and amounts of alcohol consumed. Moreover, it is critical to screen the patient for suicidal ideation to confirm or disprove the diagnosis of major depressive disorder. Lastly, I would start motivational interviewing to ensure that L. understands her addiction problems and considers going to a rehabilitation program.
References
Carvalho, A. F., Heilig, M., Perez, A., Probst, C., & Rehm, J. (2019). Alcohol use disorders. The Lancet, 394(10200), 781-792. Web.
McHugh, R. K., & Weiss, R. D. (2019). Alcohol use disorder and depressive disorders. Alcohol Research: Current Reviews, 40(1), 18. Web.
Somer, E. (2019). Trauma, dissociation, and opiate use disorder. Current Addiction Reports, 6(1), 1520. Web.
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