Patient Information:
Initials: AB Age: 28 Sex: Female Race: White
Cc (Chief complaint): ‘I feel scared people are going to know I was in a rehab’. Yes, I smoke crack, and I know I don’t want to go back to feeling horrible again because when I don’t smoke it, I get worse. And when I have it, I feel good. And then it’s gone. And then I know that I’m going to be needing another hit. ‘Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.
HPI: AB is a 28 years old white female who presents to the unit with complaints of feeling horrible due to use of cocaine. AB reported to the hospital to seek help due to her cocaine addiction. She is too anxious and restless, and her concentration is low. She is also angry and depressed, and she cries while being interviewed. AB accepts that she is addicted and understands that she will need to remain in rehab for a while. However, she is afraid that people will know about it, and even employers will not consider her for employment. She has a boyfriend who abuses cocaine, smocks tobacco, and drinks a lot of alcohol. Her boyfriend introduced her to cocaine abuse. AB is angry about a cheating boyfriend whom she found having sex with his workmate. AB and her boyfriend are workmates too. Her main concern is getting help with cocaine addiction but does not want to be admitted to a rehab center. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.
Past psychiatric history: AB was first diagnosed with bipolar I disorder at 22 years, a year after completing school. She was started on valium 20mg intravenous dose and chlorpromazine 200mg STAT doses and Haldol 10mg BD and Tegretol 200mg BD as maintenance doses. Six months before hospital admission, she had complete a three-month rehabilitation to manage substance abuse. However, she experienced adverse side effects of antipsychotics that forced the caregiver to tapper down Tegretol doses to 100mg BD. The condition has relapsed twice since; however, both have been managed out of the hospital. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.
Current Medication: AB was discharged three months later on Haldol 5mg BD and Tegretol 100mg OD. She was also attending psychiatric clinics where the primary caregiver was updating the same drug’s list on her medical records. The caregiver tapered down the dosage tapered down due to noticeable improvement in AB’s mental health. She, however, stopped taking the medication a year ago.
Allergies: No known food and drug and allergies (NKFDA).
Therapies: AB was booked for psychotherapy sessions once every week as the frequency reduced gradually with improving conditions. Some of these sessions included group therapy that significantly improved her condition. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.
Family Hx: ABs Dad died of liver cirrhosis at 45 years. Five years ago, her mother was diagnosed with bipolar depressive disorder. She was started on Haldol 5mg BD and Tegretol 100mg OD and other behavioural therapies, which responded positively. Two of her paternal uncles are alcohol addicts.Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders. Lisa’s paternal grandfather had diabetes and hypertension, and he used to smoke tobacco and occasional alcohol drinker. He succumbed to a heart attack. Lisa’s elder brother was involved in a road accident while drunk driving with a group of friends. Her maternal grandfather was a known psychiatric patient with relapsing bipolar depressive disorder. He was admitted more than five times at a psychiatric unit. He committed suicide by jumping down the cliff. Her maternal uncles also abuse alcohol. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.
Substance Use History: AB started consuming alcohol at 20 years in college after she met college friends in her second last year who introduced her to alcohol, tobacco and cocaine. AB was consistent with alcohol and not the rest before she met her current boyfriend. Three months ago, her boyfriend introduced her to cocaine, which has become addicted to. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.
Social Hx: AB is the last born in a family of three with two elder brothers. Her Dad died w
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