NRNP 6635: Week 8 Case Study on Substance-Related Disorders Assessment
Subjective:
CC (chief complaint):
HPI:
Past Psychiatric History:
- General Statement:
- Caregivers (if applicable):
- Hospitalizations:
- Medication trials:
- Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
- Current Medications:
- Allergies:
- Reproductive Hx:
ROS:
- GENERAL:
- HEENT:
- SKIN:
- CARDIOVASCULAR:
- RESPIRATORY:
- GASTROINTESTINAL:
- GENITOURINARY:
- NEUROLOGICAL:
- MUSCULOSKELETAL:
- HEMATOLOGIC:
- LYMPHATICS:
- ENDOCRINOLOGIC:
Objective:
Physical exam: if applicable
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
Solution
Lisa Tremblay is a 33-year-old Caucasian female currently admitted to a detoxification facility in Naples, Florida. She presents for evaluation and possible transition to long-term rehabilitation. Lisa reports a prolonged history of polysubstance use, including daily opiate use (approximately $100/day), daily alcohol consumption (about ½ gallon of vodka), and occasional cannabis use (1–2 times per week with a medical card). She expresses ambivalence about entering long-term treatment but acknowledges the need for sobriety, particularly to begin hepatitis C treatment. She denies suicidal or homicidal ideation at this time. Symptoms include decreased appetite, poor sleep (5–6 hours nightly), elevated anxiety, and emotional dysregulation. Her usage appears to have escalated following a history of childhood trauma and social isolation. Her insight is partial.
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