Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Lisa Pittman, 29-year-old female

CC (chief complaint): Feeling scared and worried about joining a rehab.

HPI: Lisa Pittman is a 29-year-old female who presents in a detox facility with thoughts of long-term rehabilitation. The patient provides information that she feels worried about joining a rehab. She reports that she feels scared today. She reports that she sought help because she is scared. When asked about it, she reports that she is scared of everything. She gives further clarification that she does not want people to call her an addict or find out that she is an addict. She reveals that she uses cocaine and has been using it ever since she got back with her boyfriend. It is her boyfriend who introduced her to using cocaine, and she says that she liked the feeling. She compared the feeling to the feeling one gets when dancing with butterflies. Lisa describes the reason she doesn’t want to go to rehab is that she fears the stigma. She is fearful of people finding out she has been to rehab. She is fearful that she might never be hired if people knew she had been to rehab. Another reason she gives is that rehabs are dirty.

Past Psychiatric History: Not Known

Substance Current Use and History: She has been smoking crack cocaine daily. She has a medical card for cannabis and takes it 1-2 times weekly. She also takes 2-3 drinks of alcohol once weekly.

Family Psychiatric/Substance Use History: Her mother has a history of anxiety and is on benzodiazepines. Her brother has a history of opioid use.

Psychosocial History: She has previously been convicted for drug possession and theft. She is currently on a 2-year probation. She occasionally has randomized drug tests. She has a history of sexual abuse from when she was a child aged 5-7. The perpetrator was her father, who is in prison for the offence. She is estranged from her father. She has an elder brother with who she has not had contact with for the last 10 years. She also has a boyfriend.

Medical History:

Past medical history: The patient has Hepatitis C, for which she is considering treatment.

Current Medications: No current medications

Allergies: NKDA

Reproductive Hx: The patient has one child, a girl.

ROS:

GENERAL: Alert. Well-oriented to person, place, and time.

HEENT: Normal vision and visual fields; mucous membranes are moist, there is no lymphadenopathy, and the neck is supple.

SKIN: no lesions or rashes

CARDIOVASCULAR: S1 and S2 heard. No murmurs.

RESPIRATORY: CTA bilaterally

GASTROINTESTINAL: No nausea, vomiting, constipation, diarrhea, or abdominal pain.

GENITOURINARY: No hematuria or dysuria

NEUROLOGICAL: No fainting, no paralysis, seizures, or weakness; no tremors or memory changes.

MUSCULOSKELETAL: No joint stiffness or pains.

HEMATOLOGIC: No bleeding, bruising, or anemia.

LYMPHATICS: No lymphadenopathy

Objective:

Physical exam: The patient weighs 140 lbs. and her height is 5’6”. Her pulse rate is 101 beats per minute. Her blood pressure is 178/94 mmHg, while her temperature is 99.8.

Diagnostic results: ALT 168, AST 200, ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS positive for cocaine, THC. Negative for alcohol. All other labs are within normal limits.

Assessment:

During the assessment, the patient is in denial that she is an addict. She seems to be unaware that cocaine is addictive and that she is addicted to it. She believes it because her boyfriend, Jeremy, says that it is not addictive. She also says that she does not need help with her addiction.

Mental Status Examination:

On examination, the patient is well-kempt, conscious, and attentive. Her level of concentration is normal. She has normal speech and motor functions. She is well oriented to time, place and person. Her memory is intact, both short—term and long-term. Her mood and affect are congruent. She has poor insight into her condition. Her judgement is affected.

Primary diagnosis: My primary diagnosis is cocaine use disorder. This is a substance use disorder (SUD). SUDs involve both physical and psychological dependence on the substance of use. Dependence is characterized by an inability to control the use of that substance. Prolonged stress plays a role in the development of drug-seeking behaviour. Stimulants such as cocaine act by preventing the reabsorption of seroton