NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
Subjective:
CC (chief complaint): ‘I am afraid to go to the rehab.’
HPI: Lisa Pittman is a 29-year-old female that has come to the unit for treatment for Hep C+ and needs to get clean first. She is thinking of going for long-term rehab but is fearful of what people will say and the perception that they are dirty. Lisa has been smoking crack cocaine, approximately $1000 daily, cannabis 1-2 times weekly, and 2-3 alcoholic drinks weekly. She also has a history of theft convictions and drug possessions and is on a 2-year probation with randomized drug screens. Her laboratory values have demonstrated abnormal results in ALT, AST, bilirubin, albumin, GGT, and positive for cocaine. She has a history of sexual abuse as a child, with perpetrator being her father who was imprisoned for the offence and drug charges. Lisa is currently in a relationship with Jeremy, who also abuses drugs and alcohol. She has a daughter who lives with her friends.
Past Psychiatric History:
- General Statement: I am afraid of going to the rehab
- Caregivers (if applicable): none
- Hospitalizations: Lisa denied any history of hospitalizations
- Medication trials: Lisa denied any history of medication trials
- Psychotherapy or Previous Psychiatric Diagnosis: Lisa denied any history of psychotherapy or previous psychiatric diagnosis
Substance Current Use and History: Lisa currently abuses cannabis 1-2 times weekly, smokes crack cocaine, and drinks 2-3 alcoholic drinks weekly
Family Psychiatric/Substance Use History: There is history of substance abuse in Lisa’s family. Her father was imprisoned for sexually abusing her and drug offenses. Her mother has a history of benzodiazepine use. Her older brother has history of opioid abuse. Her mother has a history of anxiety.
Psychosocial History: Lisa is not married. She is in a relationship with Jeremy. She current works and struggles to remain clean so that people do not talk about her. She has a daughter who stays with her friends.
Medical History: Lisa denied any history of hospital admission, surgeries, or blood transfusion.
- Current Medications: Lisa is not currently using any medications
Allergies: She is allergic to Amoxicillin. She denied other forms of allergies.
- Reproductive Hx: Her menarche was when she was 15 years. Her last menstrual period was one week ago. She is currently not using any contraceptive method. She denies any menstrual problems. She is sexually active. She does not use any protection when engaging in sexual intercourse. She has one child. She denied any history of pregnancy loss. She denied history of sexually transmitted infections. She denied dysuria, urgency, and frequency. She was sexually abused when she was aged 5-7 by her father.
ROS:
- GENERAL: Lisa appears poorly groomed for the occasion. She is slightly underweight for her age. She does not demonstrate restlesses, agitation, and denies fever
- HEENT: Eyes: Lisa denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: She also denies hearing loss, sneezing, congestion, runny nose, or sore throat.
- SKIN: Lisa denies rash or itching. There are evident needle prick marks on the arms.
- CARDIOVASCULAR: Lisa denies chest pain, chest pressure, or chest discomfort. She also denies palpitations or edema.
- RESPIRATORY: Lisa denies shortness of breath, cough, or sputum.
- GASTROINTESTINAL: She denies anorexia, nausea, vomiting, or diarrhea. She also denies abdominal pain or blood. She reports decline in appetite. She prefers getting higher to eating.
- GENITOURINARY: Lisa denies burning on urination, urgency, hesitancy, odor, odd color
- NEUROLOGICAL: Lisa denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. She also denies change in bowel or bladder control.
- MUSCULOSKELETAL: Lisa denies muscle, back pain, joint pain, or stiffness.
- HEMATOLOGIC: Lisa denies anemia, bleeding, or bruising.
- LYMPHATICS: She denies enlarged Order this paper