BACKGROUND
Mrs. Maria Perez is a 53 year old Puerto Rican female whopresents today due to a rather embarrassing problem.
SUBJECTIVE
Mrs. Perez admits that she has had problems with alcoholsince her father died in her late teens. She reports that she has struggledwith alcohol since her 20s and has been involved with Alcoholics Anonymous onand off for the past 25 years. She states that for the past 2 years, she hasbeen having more and more difficulty maintaining her sobriety since the openingof the new Rising Sun casino near her home. Mrs. Perez states that she and afriend went to visit the new casino during its grand opening at which point shewas 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-stakesgames. She states that this often gives way to more drinking and more recklessgambling. She also reports that her cigarette smoking has increased over thepast 2 years and she is concerned about the negative effects of the cigarettesmoking on her health.
She states that she attempts to abstain from drinking butshe gets such a high from the act of gambling that she needs a few drinks toeven out. She also notices that when she drinks, she doesnt smoke as much,but she enjoys smoking when she is playing at the slot machines. She alsoreports that she has gained weight from drinking so much. She currently weights122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.
Mrs. Perez is quite concerned today because she borrowedover $50,000 from her retirement account to pay off her gambling debts, and herhusband does not know.
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female who is alertand oriented to person, place, time, and event. She is dressed appropriatelyfor the weather and time of year. Her speech is clear, coherent, and goaldirected. Her eye contact is somewhat avoidant during the clinical interview.When you make eye contact with her, she looks away or looks down. Shedemonstrates no noteworthy mannerisms, gestures, or tics. Her self-reportedmood is sad. Affect is appropriate to content of conversation andself-reported mood. She denies visual or auditory hallucinations, and nodelusional or paranoid thought processes are readily appreciated. Insight andjudgment are grossly intact; however, impulse control is impaired. She iscurrently denying suicidal or homicidal ideation.
Diagnosis: Gambling disorder, alcohol use disorder
DecisionPoints:
Select what you should do:
Vivitrol (naltrexone) injection, 380 mg intramuscularly inthe gluteal region every 4 weeks
Antabuse (disulfiram) 250 mg orally daily
Campral (acamprosate) 666 mg orally three times/day
DecisionPoint One
*Vivitrol (naltrexone) injection, 380 mg intramuscularly inthe gluteal region every 4 weeks
RESULTS OF DECISION POINT ONE
Client returns toclinic in four weeks
Mrs. Perez says shefeels wonderful as she has not touched a drop of alcohol since receivingthe injection
Client reports thatshe has not been going to the casino, as frequently, but when she does go shedrops a bundle (meaning, spends a lot of money gambling)
Client She is also stillsmoking, which has her concerned. She is also reporting some problems withanxiety, which also has her concerned
DecisionPoint Two
*Refer to a counselor to address gambling issues
RESULTS OF DECISION POINT TWO
Mrs. Perez returns in4 weeks and reports that the anxiety that she had been experiencing is gone.
She reports that shehas met with the counselor, but she did not really like her.
She also startedgoing to a local meeting of Gamblers Anonymous. She states that last week, forthe first time, she spoke during the meeting. She reports feeling supported inthis group.
DecisionPoint Three
Explore the issue that Mrs. Perez is having with hercounselor, and encourage her to continue attending the Gamblers Anonymousmeetings
Guidance to Student
Although controversy exists in the literature regarding howlong to maintain a client on Vivitrol, 8 weeks is probably too soon to considerdiscontinuation. The psychiatric mental health nurse practitioner should explorethe issues that Mrs. Perez is having with her counselor. As will be covered inmore depth in future courses, ruptures in the therapeutic alliance can resultin clients stopping therapy. Clearly, if the client does not continue withtherapy, the likelihood of the gambling problem spontaneously remitting islower (than had the client continued to receive therapy). Recall that there areno FDA-approved treatments for gambling addiction. The mainstay of treatmentfor this disorder is counseling. Since Mrs. Perez reports good perceivedsupport from the Gamblers Anonymous meetings, she should be encouraged tocontinue her participation with this group.
You need to discuss smoking cessation options with Mrs.Perez in order to address the totality of addictions, and to enhance heroverall health.
Introduction to the case (1 page)
- Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
- Which decision did you select?
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
- Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
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