BACKGROUND Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.” SUBJECTIVE Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health. She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight. Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money. MENTAL STATUS EXAM The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation. Diagnosis: Gambling disorder, alcohol use disorder Decision Point One Antabuse (Disulfiram) 250 mg orally every morning ON Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks Antabuse (Disulfiram) 250 mg orally daily Campral (Acamprosate) 666 mg orally three times/day E · Client returns to clinic in four weeks · Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse · Clientis She is also reporting that she is having “out of control” anxiety.. Decision Point Two Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms RESULTS OF DECISION POINT TWO Decision Point Two Select what the PMHNP should do next: Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety Refer to a counselor to address gambling issues Add on Chantix (varenicline) 1 mg orally BID Client returns to clinic in four weeks Mrs. Perez reports that when she first received the valium, it helped her tremendously. She states “I was like a new person- this is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her valium early. She is asking today for you to increase the valium dose or frequency Although she reports that her anxiety is gone, she still reports suicidal ideat…
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