WK#6 Addiction

NR 546 Week 6 Case Study

9.24 MWS

Subjective Objective

The client L.B. is a 38-year-old, white female

patient seen today for a follow-up visit at her

intensive outpatient program (IOP) treatment

clinic. She has a history of Alcohol Abuse and

Opioid abuse (Typically takes Norco or

Oxycontin). Also has a mental health history

of depression with suicidal ideation.

Client’s Chief Complaints:

“I can't stop drinking, and I feel like I have no

reason to live.”

History of Present Illness

L.B. presents to the IOP clinic currently

intoxicated. She reports a longstanding history

of alcohol abuse, which has worsened over the

past year as well as occasional opioid abuse.

L.B. describes feeling persistently depressed,

hopeless, and having suicidal thoughts over the

past month. She admits to daily alcohol use as a

way to cope with her depressive symptoms.

Also admits to occasional cannabis use

(smoking)

Additionally, L.B. acknowledges a long-

standing history of alcohol (ETOH) abuse that

started when she was 16 and started abusing

opioids when she was 22 after a car accident.

She attributes her drinking to trying to cope

with stressors in her life. She reports consuming

a bottle of wine daily, often to the point of

intoxication, to numb her emotional pain and

alleviate her depressive symptoms. She

acknowledges that her alcohol use has

worsened over the past few months, coinciding

with the escalation of her worsening depressive

symptoms. She admits to drinking a bottle of

wine a day. Reports she consumed a bottle

today before her arrival at the IOP clinic today.

She also states she last took “a few” OxyContin

2 weeks ago. She reports she will buy this off

the street or from friends/family members.

Physical Examination:

Height: 5’5’ weight: 160 lb.

General: Slightly disheveled appearance, strong odor of

alcohol, appears older than stated age

Vital Signs: BP 138/90, T 97.9°F, P 95, RR 18, SpO2 97%.

Lab work:

AST = 67 IU/L;

ALT = 43 IU/L;

GGT= 36U/L; other liver function tests are WNL.

Hemoglobin =12.5; hematocrit = 38; MCV =95; triglycerides =

200 mg/dl.

Blood alcohol level (BAC)

• 0.20 mg/dL

Toxicology Screen:

• Positive for THC

• Negative for opioids, benzodiazepines, or other

substance

Mental status exam:

Appearance: Disheveled, appears older than stated age, smell

of alcohol. She is tearful and displays minimal eye contact

throughout the examination.

Alertness and Orientation: Fully oriented to person, place,

time, and situation.

Behavior: Cooperative but visibly agitated. She often loses

her train of thought mid-sentence.

Speech: Slurred, slowed.

Mood: Depressed and reports feeling overwhelmed by

emotional pain.

Affect: Flat, incongruent with stated mood.

NR 546 Week 6 Case Study

9.24 MWS

L.B. reports experiencing significant distress in

multiple areas of her life, including strained

relationships with family members, difficulty

maintaining employment due to frequent

absenteeism, and financial instability. She

admits to feeling isolated and disconnected

from loved ones, despite their attempts to offer

support.

L.B. expresses a strong desire to get help. She

acknowledges the severity of her symptoms and

the urgency of seeking help, recognizing that

she is unable to cope with her emotional pain

on her own and her drinking is out of control.

Past psychiatric history:

• Diagnosed with alcohol abuse disorder

and opioid use disorder 8 years ago but

never followed up for treatment.

• Diagnosed with depression 10 years ago

but was not consistently treated.

• No history of psychiatric

hospitalizations. Has been to rehab for

her ETOH abuse 5 years ago but left

because she “didn’t like it” Denies ever

attempting suicide.

Past Medical History: Hypertension,

Gastroesophageal reflux disease (GERD)

Medications:

Lisinopril 20 mg daily

Prilosec 20 mg daily

Substance Abuse History:

• Began drinking at age 16.

• Began abusing opioids at age 22

• Daily alcohol consumption,

approximately a bottle of wine per day.

• Frequent opioid abuse-Last use 2 weeks

ago consisting of several oxycontin.

• Occasional use of marijuana.

• Smokes tobacco ½ pack a day

Thought Process: Linear but slow. Often veering off-topic

and providing excessive detail in her responses.

Thought content: Expresses feelings of hopelessness and

worthlessness, admits to suicidal ideation without a specific

plan. She denies experiencing any delusions or

hallucinations. Denies intent to harm others

Perceptions: Denies experiencing any perceptual

disturbances, such as auditory or visual hallucinations.

Memory: Recent and remote WNL

Judgement/Insight: Poor insight into her alcohol use and its

impact; judgment impaired by intoxication.

Attention and observed intellectual functioning: Appears

intact, with no evidence of cognitive deficits or impairment

in orientation, attention, or memory.

Fund of knowledge: Fair general fund of knowledge and

vocabulary

NR 546 Week 6 Case Study

9.24 MWS

Family History

• Father had alcohol use disorder and died

by suicide.

• Mother has a history of depression.

• One brother with no known psychiatric

or medical conditions.

Social History

• Divorced, lives alone.

• Works as a waitress but has had

increasing absenteeism due to her

drinking.

• Limited social support, estranged from

most family members.

• High school graduate.

Trauma history:

Reports physical abuse by her father during

childhood.

Witnessed father’s suicide at age 14

Review of Systems

• General: Fatigue, low energy levels.

• Cardiovascular: Palpitations

occasionally.

• Respiratory: No shortness of breath or

cough.

• Gastrointestinal: Frequent nausea,

occasional vomiting, poor appetite.

• Musculoskeletal: No joint pain or

muscle aches.

• Neurological: No seizures, occasional

headaches. Exhibits tremors in her

hands.

• Sleep: Difficulty falling and staying

asleep, averaging 3-4 hours per night.

• Allergies: NKDA,

Alcohol Use Disorder (F 10.20)

Opioid Use Disorder (F11.20)