NRNP/PRAC 6635 Week 8 Substance-Related and Addictive Disorders Sample

Name: LP       Age: 29 years             Gender: Female

Subjective:

CC (Chief Complaint): “Am scared of going to a rehab because I don’t want to be what people think I am – an addict”

HPI (History of Presenting Illness): LP is a 29-year-old white female who has visited the clinic because she is worried about going to rehab. She is also worried that people think she is a drug addict. Subjectively, she denies this at first. LP reports that she would not want to go rehab centers because they are very dirty and she is sick of such places. Even though she denies being addicted to the various substances, she reports using substances such as crack cocaine, marijuana, and alcohol.

NRNP/PRAC 6635 Week 8 Substance-Related and Addictive Disorders Sample

Past Psychiatric History: LP has been convicted for theft and illegal possession of illicit such stances. She is currently on probation for 2 years with occasional drug screens that are always randomized. However, she had not been treated for any mental illness or admitted for any psychiatric conditions

Substance Current Use and History: LP admits to taking alcohol occasionally. She takes 2-3 drinks weekly and uses marijuana about twice a week. She also smokes crack cocaine about US $100 worth daily. She believes that she cannot function properly without this drug. She is aware that she needs to stop using it but the urge to get more after the effects of the previous dose wears off. She was initiated by her boyfriend, Jeremy into using this substance. She admits that she needs help in stopping this usage but is worried that it would be labeled as an addiction. Whenever she doesn’t smoke crack cocaine, she feels horrible and the feeling gets worse as time goes by. Therefore, she is contemplating a long-term rehabilitation that would make people believe that she is a drug addict. Smoking cocaine makes her feel like she is dancing with butterflies. Her boyfriend who initiated her into using this substance reassured her that everything is okay and she clings on to believe that she doesn’t need the rehabilitative care.

Family Psychiatric/Substance Use History: LP’s mother lives in Alabama. She has a history of benzodiazepine use. She was also diagnosed with an anxiety disorder. Her father was charged and convicted for drug abuse about 10 years ago. The elder brother has a positive history of opioid use. He has not contacted the family in the last 10 years. No family member has a known psychiatric illness.

Psychosocial History: LP lives with her boyfriend, Jeremy, who she left due to infidelity and spendthrift behavior. Her boyfriend used to use their joint business money to settle his debts. She reports that her boyfriend also uses the substances that she uses but is not addicted. She took him back in because she believes that this time, he would fulfill his pledges to repay slowly the amount of business money they have lost since they started having relationship issues. LP works together with her boyfriend doing IT orders for various businesses. She sleeps for about 4-5 hours a day. She reports losing appetite and prefers getting high to eating. LP also reports that he was sexually abused during her childhood by her father who she has sconce estranged herself from. This happened she was between 5 and 7 years old. She reports no depressive symptoms or suicidal ideations.

Medical History: LP is not hypertensive, diabetic, epileptic, or asthmatic. She reports no history of significant hospitalizations in the past. Her surgical history is unremarkable.

Current Medications: none

Allergies: She is allergic to amoxicillin. She develops skin rashes when she takes amoxicillin. She has no known food allergies or intolerances

Reproductive Hx: LP is para 1+0. Her child, a daughter, lives with her friends. The father is unknown and she declares that Jeremy is in no way related to her daughter. She denies a history of sexually transmitted diseases. She went for cervical cancer screening about 18 months ago and the findings were unremarkable for any cytologic changes. She uses no contraceptives and denies protective sex. She currently has one sexual partner, Jeremy. She reports a history of multiple sexual partners before meeting Jeremy

ROS:

  • GENERAL: no weakness or fever reported but reports occasional episodes of malaise.
  • HEENT: no headache, vertigo, double or blurry vision, anosmia, nasal congestion, sore throat, or dysphagia. She reports occasional runny nose but without bleeding or congestion
  • SKIN: no skin itchiness or rashes
  • CARDIOVASCULAR: occasional palpitations are reported with sweating. However, she reports that these are short-lived and are relieved by smoking crack cocaine. No edema of the extremities, puffy face, neck veins distension, chest pain, or fatigue is reported.
  • RESPIRATORY: no cough, sputum production, hemoptysis, dyspnea, wheezes, or chest tightness is reported
  • GASTROINTESTINAL: No nausea, vomiting, diarrhea, abdominal pains, distension, constipation, bloating, burping, or hematemesis was reported. She reports a tinge of yellowing in the eyes that were never present until 2 weeks ago. However, she denies pain in the right upper abdomen
  • GENITOURINARY: no dysuria, hematuria, nocturia, or frequency is reported. She denies genital itchiness or pain
  • NEUROLOGICAL: no urinary or bowel incontinence, no paralysis, tingling, seizures, numbness, dizziness, or weakness reported.
  • MUSCULOSKELETAL: n joint pain, stiffness, swelling, or deformities
  • HEMATOLOGIC: no easy bruising, epistaxis, or disorders of clotting
  • LYMPHATICS: no edema or extremities
  • ENDOCRINOLOGIC: no intolerance or cold and heat, no goiter, or polyuria.

Objective:

Physical Exam: vital signs 99.8°F, 178/94 mmHg, 101 – pulse rate, BMI=22.5

Diagnostic Results: diagnostic lab results showed elevation in aspartate transaminase, alanine transaminase, bilirubin, and Gamma-Glutamyl Transferase (GGT). Urodynamic studies showed positive findings for tetrahydrocannabinol and cocaine but not alcohol. Blood alcohol level (BAL) was zero.

Assessment:

Mental Status Examination: LP is a 29-year-old white female who is well kempt and dressed appropriately. She looks her stated age. She appears confused and anxious but is oriented to place and person. She has no obvious tremors or signs of abnormal motor activity. She doesn’t maintain eye contact with the examiner adequately but her concentration is good. Her speech is coherent but with fluctuating volume, rhythm, and rates. She has a flight of ideas and is easily distractible. Her thought process is logical and there is no evidence of delusional thinking. She has no hallucinations. Her mood is subjectively worried and the affect is congruent to the mood. Her insights are fair but the judgment is poor.

Differential Diagnoses:

304.20 (F14.20) Cocaine use disorder. Severe: The patient meets many criteria for diagnosis of cocaine use disorder according to the DSM-5 (American Psychiatric Association, 2013). She has cravings for the substance, repeated attempts to quit the use, withdrawal, neglect of major social roles, deterioration in social life, and relationship issues (Gomez et al., 2019). Her substance use disorder can be graded as severe. Her UDS test was positive for cocaine.

292.89 (F14.280) Cocaine-induced anxiety disorder: The patient is constantly worried about people thinking that she is an addict. She appears anxious and her mood was subjectively worried. All these could be attributed to cocaine because it is the major substance of abuse from the history of the patient (He et al., 2019).

305.20 (F12.10) Mild Cannabis Use Disorder: She uses cannabis about twice a week despite her addiction to other substances. Deterioration of her social life is evident from her substance uses. Her UDS is positive from cannabis tetrahydrocannabinol (THC). The severity of her condition is mild because she meets only two of the criteria by the DSM-5 (American Psychiatric Association, 2013 NRNP/PRAC 6635 Week 8 Substance-Related and Addictive Disorders Sample). However, other criteria were not fully assessed from the history.

305.00 (FI 0.10) Mild Alcohol Use Disorder: LP meets only two of the criteria for diagnosis of alcohol use disorder (Kim et al., 2021). She recurrently uses alcohol even in situations where her life is threatened by addiction to other substances. She also has a mild craving for alcohol (Fitzgerald & Puttler, 2018) during the interview as she thought that would help solve her anxiety. However, her BAL level is zero.

Cocaine Intoxication: even though her hypertension is asymptomatic, the assessment of vital signs showed elevation of blood pressure that could only be explained by her addiction to cocaine (Richards & Le, 2021). Other presentations that point towards cocaine intoxication in this patient include fast heart rate, decreased sleep, and anxiety, decreased appetite, and paranoia (American Psychiatric Association, 2013). The patient has developed distrust in her relationship with the boyfriend and thinks the boyfriend is cheating with another lady with the same name as hers.

Hepatitis: the derangement in liver function tests and jaundice point towards hepatitis. Her missing history of IV drug use is not adequate to make this assumption (Bouquet et al., 2021). Therefore, lab tests for the hepatitis C virus would suffice

Reflections: The patient has multiple substance use disorders. If I was to do the interview again with this patient, I would try to rule out alcohol used disorder by screening for alcohol dependence. I would use the CAGE criteria. Exploration of other substances such as marijuana, and cocaine would be the mainstay of my interview and evaluation. Assessment of her social environment would help me determine the best management modalities for her illnesses.

NRNP/PRAC 6635 Week 8 Substance-Related and Addictive Disorders Sample References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R)) (5th ed.). American Psychiatric Association Publishing.
  • Bouquet, E., Pain, S., Fauconneau, B., Lesbordes, M., Frouin, E., Silvain, C., & Pérault-Pochat, M.-C. (2021). Cocaine-induced acute hepatitis: A diagnosis not to forget. Clinics and Research in Hepatology and Gastroenterology45(1), 101462. https://doi.org/10.1016/j.clinre.2020.05.010
  • Fitzgerald, H. E., & Puttler, L. I. (Eds.). (2018). Alcohol use disorders: A developmental science approach to etiology. Oxford University Press.
  • Gomez, K., Berumen, A., Schmitz, J., Lane, S., Green, C., & Wardle, M. (2019). Trauma, inflammation, and anhedonia in cocaine use disorder. Journal of Affective Disorders254, 140. https://doi.org/10.1016/j.jad.2018.10.310
  • He, C., Wang, J., Ma, M., & Wang, H. (2019). Sexual cues influence cocaine-induced locomotion, anxiety, and the immunoreactivity of estrogen receptor alpha and tyrosine hydroxylase in both sexes. Journal of Neuroendocrinology31(6), e12720.
  • Kim, J. I., Park, H., Min, B., Oh, S., Lee, J.-H., & Kim, J.-H. (2021). The mediation effect of depression and alcohol use disorders on the association between post-traumatic stress disorder and obstructive sleep apnea risk in 51,149 Korean firefighters: PTSD and OSA in Korean firefighters. Journal of Affective Disorders292, 189–196. https://doi.org/10.1016/j.jad.2021.05.077
  • Richards, J. R., & Le, J. K. (2021). Cocaine Toxicity. In StatPearls. StatPearls Publishing.