substance abuse | Coursehero Helper

I don’t know how to handle this History question and need guidance.

38 y/o male

HISTORY OF PRESENT ILLNESS:

A 38 y/o male was sent to psychiatry directly from his internist’s office.That morning the pt. and his wife presented to the doctor’s office without an appointment, and the pt. expressed feelings of being overwhelmingly depressed.He had developed a plan to commit suicide, which included taking a bottle of Tylenol and drinking “as much vodka as it takes”. The internist performed a thorough evaluation, drew labs and called 911 to have the patient brought to the ER.

When you encounter the pt., he is visibly upset and clinging to his wife. The couple explains that they separated a month ago, because the patient “just couldn’t be a husband anymore”.

Over the past 6 weeks he has become isolative, complained of decreased energy, concentration, appetite, and sleep.He had lost his job as a house painter 6 months earlier.The patient no longer enjoyed the caretaking of the couple’s 2 children, ages 4 and 6—a drastic change from the role he had previously enjoyed as a father.

You ask the patient when he first began feeling down.He states clearly, “When my mother died, one and a half years ago.”He said that he had been feelingguilty over the circumstances of her death and wishing he had been closer to her in the years preceding her death.The wife notes with concern: “That was just anbout the time you started drinking so heavily, as well.”As you question further, you determine that the pt. has been drinking daily since his mother’s death.He estimates that he is drinking 6 beers a day.He admits that drinking is a problem, and he actually tried to stop drinking two weeks before this visit.The patient said:“My wife kicked me out of the house, I missed my kids, I didn’t have a job…I knew something was wrong.”He noted that in the days after stopping drinking, he experienced some shakiness and symptoms “like there were bugs under my skin.”He added that having a beer made these symptoms subside.Last night he had become very upset after calling his wife to check on the children and finding they were not at home.He sat in his hotel room and thought, “I can’t go on living like this.”He called his wife at 6 am the next day and said he thought he might kill himself.She immediately brought him to the internist’s office.

PAST PSYCHIATRIC HISTORY:

The pt. has never been psychiatrically hospitalized, nor has he seen a psychiatric provider before.He recalls having been depressed only once earlier in his life, during his 20’s, but he did not seek treatment at that time.Although the pt. is currently suicidal, he denies any past suicidal thinking and has never made previous suicide attempts.

PAST MEDICAL HISTORY:

HTN, Hypercholesterolemia.

MEDICATIONS:Metoprolol, 50 mg bid.

FAMILY HX:

The pts’s father has a hx of alcohol dependence, and his mother had HTN and coronary artery disease before dying of an MI.Pt. denies any Hx of psychiatric illness in his family.

SUBSTANCE ABUSE HX:

The pt has been drinking 6 beers/day for the past year and a half; before that he was not drinking on a daily basis.He has a remote history of similar drinking in his 20’s during his first divorce, but he was able to quit “cold turkey” and has never been to any detox. facility.He experienced symptoms of with drawl when he quit but has no history of withdrawal seizures.He denies use of marijuana, heroin, cocaine, or other substances.He smokes ½ pk per day of cigarettes.

SOCIAL HISTORY:

The pt describes a chaotic childhood, since his father was ‘

“unpredictable” because of his drinking.He finished high school and then went to vocational school.He became a house painter and worked sporadically.He was married in his early 20’s and has a 17 y/o daughter who is being raised by her mother.He married his current wife 8 yrs. Ago; the marriage was functioning well until the recent became a problem.

MENTAL STATUS EXAM:

The pt. is a white male who appears exhausted and mildly disheveled in a sweatshirt, baseball cap, and jeans.He frequently becomes teary throughout the evaluation and has poor eye contact, although he is cooperative with the interview.His stature is slumped, even seated in the chair, and he often leans forward and hides his face in his hands.His speech is notable for increased latency and paucity of words.His affect is dysphoric, congruent with the context of the discussion, and does not brighten throughout the interview.His thought process is linear and logical, and thought content is preoccupied with his mother’s death.The pt. has no overt delusions, he denies ideas of reference and paranoid ideation.He also denies hallucinations.He is experiencing suicidal ideation with intent and plan but denied homicidal ideations.

His insight and judgment are fair at this moment in that he knows he needs treatment.Cognitive exam is grossly intact.

LABS:

Alcohol level= 130; AST = 68 IU/L; ALT = 45 IU/L; GGT= 35U/L; other liver function tests are WNL.

Hemoglobin =13.4; hematocrit = 41; MCV =95; triglicerides = 200 mg/dl.

Include:

• Any differential diagnoses
• Your diagnosis and reasoning
• Any additional questions you would have asked
• Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
• Any labs and why they may be indicated
• Screener scales or diagnostic tools that may be beneficial
• Additional resources to give (Therapy modalities, support groups, activities, etc.)