NRNP 6635 Week 8 Assignment: Assessing And Diagnosing Patients With Substance-Related And Addictive Disorders Example Patient Information:

NRNP 6635 Week 8 Assignment: Assessing And Diagnosing Patients With Substance-Related And Addictive Disorders Example

Patient Information:

Name: Lisa Tremblay

Gender: Female

Age: 33 years old

Subjective:

CC (chief complaint): “I’m scared. Well, I don’t want to be. I don’t want to be what people say I am because if I say it I’m not going to say it because I am not going to change. I can’t.”

HPI: L.T. is a 33-year-old female of Caucasian ethnicity who has been referred for evaluation and treatment from a detox facility in Naples, FL, where she has been considering long-term rehabilitation. She is seeking a psychiatric evaluation for her anxiety and substance use issues. Currently, L.T. is not taking any psychotropic medications. L.T. expresses fear and resistance towards going to rehab, indicating her emotional distress.

The anxiety symptoms experienced by L.T. have been present since she discovered her boyfriend’s infidelity and substance use, which has led to her fear of being labeled as an addict. L.T. engages in daily substance use, including opiates, cannabis, and alcohol, which significantly impacts her daily functioning.

L.T.’s emotional distress is severe, resulting in impaired judgment, decreased appetite, disrupted sleep, and a preference for substance use over essential activities. L.T. experiences disturbances in sleep duration, sleeping for 5-6 hours. L.T. reports a decreased appetite and a preference for substance use over her eating, indicating the impact of her substance use on her nutritional intake.

Past Psychiatric History:

• General Statement: her first mental health problems started at age 26
• Caregivers (if applicable): none
• Hospitalizations: Lisa’s hospitalization occurred at the age of 26 and was specifically related to detoxification from alcohol abuse. No history of suicidal or homicidal behaviors was reported. No history of self-harm behaviors
• Medication trials: no previous psychotropic medication treatment
• Psychotherapy or Previous Psychiatric Diagnosis: no history of previous psychotherapy. She was diagnosed with alcohol use disorder at age 26.

Substance Current Use and History: Lisa regularly uses opiates daily, incurring an estimated cost of $100. She also discloses her cannabis usage occurring at a frequency of 1-2 times per week. Lisa reveals her consumption of half a gallon of vodka each day over 7 years.

Family Psychiatric/Substance Use History: Lisa Tremblay’s father tragically passed away as a result of suicide (X). Additionally, he was responsible for perpetrating childhood sexual abuse, which ultimately led to his imprisonment. Lisa’s mother suffers from agoraphobia and has a troubling past of benzodiazepine abuse. Within the family dynamic, Lisa has an older brother who is currently estranged from the rest of the family. Another older brother has struggled with opioid use and has had no communication with the family for the past decade.

Psychosocial History: Lisa is the last born in a family of three.She has two older brothers, one estranged and the other struggling with opioid use. Lisa’s dropped out of school in grade 11. Lisa has an interest in entrepreneurship and digital media. She runs a business related to commercials and website development. She is currently self-employed. Her work history revolves around her business with her boyfriend, Jeremy. Lisa has a past arrest for drug possession. Lisa has experienced childhood sexual abuse by her father, but no further details are provided about additional traumatic experiences.

Medical History: She currently has hepatitis C, for which she is yet to seek care.

• Current Medications: none
• Allergies:azithromycin
• Reproductive Hx:She is para 0+0, whose LNMP was last month on the 28th. No late menarche, painful menstruation, painful coitus, or use of contraceptives reported.

ROS:

• GENERAL: No weakness, night sweats, fever, or weight loss
• HEENT: No headache, hearing problems, or blurry vision
• SKIN: no skin ulcers, chronic wounds, or itchiness
• CARDIOVASCULAR: No left-sided chest pain, no fatigue, or leg swelling
• RESPIRATORY: No shortness of breath, no cough, or chest tightness
• GASTROINTESTINAL: No abdominal pain, diarrhea, no bloating, or constipation. Reports reduced ap