Case Study Assignment: A 17-Year-Old Female Presented with Alcohol and Nicotine Abuse

Case Study Assignment: A 17-Year-Old Female Presented with Alcohol and Nicotine Abuse

Case Study Assignment: A 17-Year-Old Female Presented with Alcohol and Nicotine Abuse

Case Study: A 17-Year-Old Female Presented with Alcohol and Nicotine Abuse

SUBJECTIVE DATA

Initials: S.V                   Sex: F           Age: 17 years old               Ethnicity: African-American

Chief Complaint: “Persistent cigarette smoking and alcohol abuse.”

History of the Presented Illness

            The client S.V is a 17 years old female who presented to the clinic with persistent cigarette smoking and alcohol abuse. Upon coming to the clinic, the client reports chewing tobacco and E-cigarette vapors. She reported being unable to limit or control the consumption of alcohol despite making effort to do so. The client also revealed spending much time drinking, obtaining alcohol, or recovering from alcohol intake. Furthermore, she reported feeling a strong urge to drink alcohol. She experiences anger outbursts that are accompanied by a feeling of emptiness. The client also reported problems in physical and social relationships. She reported spending most time alone. She was no longer interested in spending time with her friends or family. She reported reduced interest in participating in social activities, including group hiking. She becomes agitated and irritated especially when her peers force her to join them in social activities. She also reported engaging in unprotected sexual intercourse with different men, resulting in recurrent urinary tract infections (UTIs). The client reported using alcohol while driving, compromising her safety and that of other passengers in the car. She has reported experiencing withdrawal symptoms, including nausea, shaking, and sweating. Consequently, she drinks to avoid these symptoms. The client is in high school and seems not interested in continuing with his education. He reports persistent poor academic performance for the last 12 months. He associated this trend with persistent cigarette smoking and repeated alcohol abuse. The client denies illicit drug use. Denies suicidal thoughts, visual or audio hallucination, or insomnia.

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Current Medications: Ceftriaxone 50mg orally daily taken to treat recurrent UTI.

Allergies: The client denies medication, environmental, and food allergies.

Past Psychiatric History: She denies a previous psychiatric diagnosis.

Psychiatric treatment/psychotherapy: Denies past psychiatric treatment or psychotherapy.

Substance Current Use and History: The client reveals using nicotine and alcohol recently. She denies using other illegal substances.

Family substance abuse history: Her father was diagnosed with alcohol use disorder

PMHx: She reported that all her childhood immunizations are up to date.  

Soc Hx: The client is a lastborn in a family of four children. She lives with her parents and her two siblings in a four-bedroom mansion in the city. Their firstborn relocated three months ago after securing a job as a clinical officer away from the city. She likes hiking, swimming, and going to the gym. However, she reports losing interest in group hiking and swimming recently. The client reports current nicotine and alcohol use. The client chews tobacco and uses E-cigarette vapors. She spends most of her time obtaining or drinking alcohol. Failure to take alcohol compromises her capacity to perform activities of daily living. She experiences sweating and shaking if she fails to use alcohol for more than 24 hours. These symptoms subside upon taking alcohol. She reports smoking more cigarettes when drunk. She denies using other illegal substances, including cocaine, heroin, or marijuana. She denies engaging in religious activities.

Fam Hx: Her parents are alive. Her father is 65yo with a history of diabetes type 2 Mellitus, alcohol use disorder (AUD), and obesity. Her mother is 57yo with hypertension, breast cancer, and high cholesterol level. She has three siblings who are healthy with no known chronic illnesses.

ROS

GENERAL: The client denies fatigue, fever, night sweat, weakness, or recent weight changes.

HEENT:

Head: The client denies injuries to the scalp, trauma, or deformities. She denies seizures, headaches, or dizziness.

Eye: She blurred or had double vision. She denies eye discharge, itching, or pain.

Ear: She denies ear pain or discharge, ear pain. She denies loss of hearing, tinnitus, or difficulty hearing.

Nose: The client denies nasal blockage, sneezing, nose bleeding, difficulty with smell, or runny nose.

Throat: The client denies difficulty in swallowing or hoarseness of voice.

Neck: Denies neck pain

SKIN: Denies skin discoloration, rashers, cracking, or itchiness.

CARDIOVASCULAR: She denies palpitations, shortness of breath, edema, or nocturnal orthopnea.

RESPIRATORY: The client denies difficulty in breathing, coughing, sputum production, or increased breathing rate.

GASTROINTESTINAL: The client denies changes in appetite, abdominal pains, nausea, constipation, heartburn, diarrhea, or vomiting.

GENITOURINARY: The client denies hematuria, frequency, dysuria, burning sensation, vaginal discharge, or incontinence.

NEUROLOGICAL: The client denies headache, dizziness, paralysis, ataxia, and change in bowel or bladder control. Denies numbness and tingling in extremities.

MUSCULOSKELETAL: Denies joint stiffness or joint swelling. Denies back pain and muscle pain.

HEMATOLOGIC: The client denies excessive bleeding or bruising. She denies anemia. LMPHATICS: The client denies lymphadenopathy or splenectomy.

PSYCHIATRY: Denies suicidal thoughts, visual or audio hallucination, or insomnia.

ENDOCRINOLOGIC: The client denies polyuria or sweating. Denies heat or cold intolerance. ALLERGIES: The client denies eczema, asthma, hives, or rhinitis.

OBJECTIVE DATA

Physical Examination

Vital signs: BP- 120/80 mmHg, PR-88, RR-19, Temp- 98.1, SpO2-99% on room air, Ht- 72”, Wt- 145 lbs.

General: The client is a 17 years old female. She is well-developed and nourished. She is smartly dressed, presentable, and neat. The client maintains an upright posture and eye contact throughout the interview. Her nutritional status seems to be good. She is attentive during the clinical interview and answers all interview questions appropriately. The client is fluent and speaks in a clear voice, and low tone. Her self-reported mood is “sad.” She seems to be in mild acute distress. Her affect and judgment are good. The client is alert and oriented to person, time, events, and place. She is future-oriented. Denies suicidal thoughts, visual or audio hallucination, or insomnia.

HEENT:

Head: Head examination indicated even hair distribution, atraumatic, and normocephalic with no scars or swellings. Head palpation did not detect tenderness or masses.

Eye: No eye discharge. Clear conjunctiva and sclera.

 Ear: Normal external auditory canal and pinna. Clear tympanic membrane with no bulging.

Nose: Normal nose shape seen on inspection. Pink and moist nasal mucous membranes. Throat: Pink and moist oral mucous membrane. No exudate in tonsils and posterior pharynx.

Neck: No scars or swellings were detected on inspection. Palpation indicated that the trachea is in the midline with no tenderness or swelling.

Musculoskeletal: Good body posture. No joint swelling. No bone deformities and normal back curvature. She demonstrates 5/5 strength.

Skin: No skin rashes, bumps, or cracking. Normal skin turgor was demonstrated.

Cardiovascular: No chest deformities or scars were seen on examination. No tenderness or edema was detected on palpitation. Her rate and rhythm were normal. S1 and S2 were heard on auscultation. No murmurs or cracking sounds.  

Respiratory: Her chest moves with respiration on inspection, No deformities or scars detected. No tenderness on palpation. Symmetrically equal chest expansion. No palpable masses. Gastrointestinal: Movement of the abdomen detected on an inspection. Her abdomen is flat with no scars or hyperpigmentation. Bowel sounds were heard in the quadrants on auscultation. Her abdomen was warm, soft, and non-tender with no organomegaly on palpation.

Genitourinary:  Normal external genitalia with shaved pubic hair on inspection. No vaginal discharge or bleeding. Her bladder was non-palpable with no suprapubic tenderness. Normal uterus size.

Neurological: The client is alert, awake, and oriented to places, events, persons, situations, and times. Depict normal thought process. Normal muscle tone.

PSYCHIATRY: Seems to be in mild distress, agitated, and anxious.

Diagnostics

1. Saliva Alcohol Testing Strip Kits: Used to detect alcohol consumption.
2. EtG Urine Alcohol Test: The test was used to detect the presence of ethyl glucuronide.

• Cotinine Test Kit: The test was conducted to assess the presence of cotinine. The results indicated a cotinine level of 200 ng/mL.

ASSESSMENT

Differential diagnosis was conducted to rule out potential health conditions based on the client’s subjective data, physical exam findings, and diagnostic test results. Potential diagnoses for this client are listed below from the most likely to the least likely diagnosis.

1. Substance use disorder – Primary diagnosis
2. Borderline personality disorder

• Major Depressive Disorder

1. Bipolar disorder

Substance Use Disorder

Substance use disorder is the primary diagnosis for this client. This condition is characterized by excessive consumption of alcohol and other drugs. Individuals with this disorder tend to spend most of their time in obtaining and drinking alcohol. Their efforts to reduce or control drinking are usually unsuccessful (Kranzler et al., 2018). Cigarette smoking is usually attributed to drug use disorder. Upon visiting the clinic, the client reported several symptoms associated with drug use disorder. The client reported chewing tobacco and E-cigarette vapors. She reported that she was unable to limit or control the consumption of alcohol despite making effort to do so. The client also revealed spending much time drinking, obtaining alcohol, or recovering from alcohol intake. Furthermore, she reported feeling a strong urge to drink alcohol. She becomes agitated and irritated especially when her peers force her to join them in social activities. She has reported experiencing withdrawal symptoms, including nausea, shaking, and sweating. Consequently, she drinks to avoid these symptoms. The client also reported persistent poor academic performance for the last 12 months. He associated this trend with persistent cigarette smoking and repeated alcohol abuse. Additionally, diagnostic tests, including Saliva Alcohol Testing Strip Kits, EtG Urine Alcohol Test, and Cotinine Test Kit were positive. Cotinine Test Kit The test results indicated a cotinine level of 200 ng/mL, indicating a regular smoker. Thus, substance use disorder qualifies as the primary diagnosis for this client.

Borderline Personality Disorder

 Borderline Personality Disorder is another potential diagnosis for this client. This condition is characterized by fear of being abandoned, unstable relationships, shifting self-image, self-destructive behaviors, and self-harm (Bozzatello et al., 2021). People with this disorder also report extreme emotional swings, chronic feelings of emptiness, and, explosive anger (Gunderson et al., 2018). The client experiences anger outbursts that are accompanied by a feeling of emptiness. She also reported problems in physical and social relationships. She also reported engaging in unprotected sexual intercourse with different men, resulting in recurrent urinary tract infections (UTIs). The client reported using alcohol while driving, compromising her safety and that of other passengers in the car. Therefore, the client qualifies for this diagnosis. However, Borderline Personality Disorder is ruled out due to the absence of significant symptoms, including fear of being abandoned and unstable relationships.

Major Depressive Disorder (MDD)

MDD is another potential diagnosis for this client. This condition is characterized by mood symptoms, including anxiety, general discontent, apathy, guilt, hopelessness, sadness, or loss of interest in activities one used to like before (Christensen et al., 2022). Upon reporting to the clinic, the client reported reduced interest in participating in social activities, including group hiking. Furthermore, MDD is characterized by behavioral symptoms, including agitation, excessive crying, restlessness, irritability, or social isolation (Kennedy, 2022). The client reported anger outbursts and spending most of her time alone. She was no longer interested in spending time with her friends or family. The client reported poor academic performance for the past 12 months. According to Feng et al. (2022) adolescents diagnosed with depressive disorder experience poor academic performance. Thus, the client qualifies for this diagnosis. Other symptoms of MDD include a change in energy levels, appetite, and sleep; fatigue; insomnia, suicidal thoughts, or changes in appetite. Therefore, MDD was ruled out in this client due to the absence of significant symptoms, including insomnia, changes in weight, fatigue, insomnia, suicidal thoughts, or visual or audio hallucination.

Bipolar I Disorder

 Lastly, this client should be diagnosed with bipolar I disorder, which is also known as manic-depressive disorder or manic depression. This condition is characterized by manic and depressive episodes. A manic episode is characterized by rapid and loud speech, increased energy, hyperactivity, insomnia, inflated self-image, excessive spending, hypersexuality, and substance abuse (Bobo et al., 2017). On the other hand, a depressive episode is characterized by low energy, loss of interest in daily activities, and suicidal thoughts (Barton et al., 2021). The client might have this disorder since she reported several symptoms, including inflated self-image, excessive spending, hypersexuality, substance abuse, and loss of interest in daily activities such as hiking with her friends. However, bipolar I disorder was ruled out due to the absence of significant symptoms, including rapid and loud speech, changes in energy level, hyperactivity, insomnia, or suicidal thoughts.

TREATMENT PLAN

            The treatment plan for substance use disorder consists of medication and pharmacological interventions. This client would be prescribed disulfiram 500 mg orally once daily as the initial dosage. The client would take this dosage for the first 2 weeks. After returning to the clinic after 2 weeks, the dosage would be titrated downwards to 250 mg orally daily based on the effectiveness of disulfiram 500 mg in improving presented symptoms. According to Kranzler and Soyka (2018), the US Food and Drug Administration has approved disulfiram, naltrexone, and acamprosate for treating alcohol use disorders due to their superiority in managing presented symptoms. In addition to medication, psychotherapies especially motivational enhancement therapy (MET) will be used in managing the client’s persistent nicotine and alcohol use.  MET is an effective intervention for managing symptoms presented by individuals diagnosed with substance use disorder (Leonardi et al., 2021). Through, around 4 sessions of MET client’s thinking and perception will be changed positively, enabling her to regulate or reduce nicotine and alcohol use. Furthermore, the treatment plan for this client will include patient education. First, the client would be educated about the dangers of persistent smoking, including increasing the risk of developing lung cancer (O’Keeffe et al., 2018). The client would also be educated about the dangers of engaging in unprotected sex, including a high risk of contracting STDs and unwanted pregnancies. According to Yakubu & Salisu (2018), substance abuse is associated with a high rate of unwanted pregnancies among adolescents. Thus, the client will be advised to abstain or use protection while having sexual intercourse.

References

Barton, J., Mio, M., Timmins, V., Mitchell, R. H., & Goldstein, B. I. (2021). Prevalence and correlates of childhood‐onset bipolar disorder among adolescents. Early Intervention in Psychiatry. DOI:https://doi.org/10.1016/j.mayocp.2017.06.022

Bobo, W. V. (2017, October). The diagnosis and management of bipolar I and II disorders: clinical practice update. In Mayo Clinic Proceedings (Vol. 92, No. 10, pp. 1532-1551). Elsevier. 10.31887/DCNS.2008.10.3.

Bozzatello, P.; Garbarini, C.; Rocca, P.; & Bellino, S. (2021). Borderline Personality Disorder: Risk Factors and Early Detection. Diagnostics, 11, 2142. https://doi.org/10.3390/ diagnostics11112142

Christensen, M. C., Wong, C. M. J., & Baune, B. T. (2020). Symptoms of major depressive disorder and their impact on psychosocial functioning in the different phases of the disease: do the perspectives of patients and healthcare providers differ?. Frontiers in Psychiatry, 11, 280. https://doi.org/10.3389/fpsyt.2020.00280

Feng, T., Jia, X., Pappas, L., Zheng, X., Shao, T., Sun, L., … & Ma, Y. (2022). Academic Performance and the Link with Depressive Symptoms among Rural Han and Minority Chinese Adolescents. International Journal of Environmental Research and Public Health, 19(10), 6026. https://doi.org/10.3390/ ijerph19106026.

Gunderson, J. G., Herpertz, S. C., Skodol, A. E., Torgersen, S., & Zanarini, M. C. (2018). Borderline personality disorder. Nature Reviews Disease Primers, 4(1), 1-20. DOI:https://doi.org/10.1016/S0140-6736(21)00476-1

Kennedy, S. H. (2022). Core symptoms of major depressive disorder: relevance to diagnosis and treatment. Dialogues in Clinical Neuroscience. 10:3, 271-277, DOI:

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. Jama, 320(8), 815-824. Doi:10.1001/jama.2018.11406

Leonardi, J. L., Josua, D., & Gomes, C. (2021). Evidence-Based Psychotherapy for Substance Use Disorder. In Drugs and Human Behavior (pp. 193-204). Springer, Cham. DOI:10.1007/978-3-030-62855-0_13.

O’Keeffe, L. M., Taylor, G., Huxley, R. R., Mitchell, P., Woodward, M., & Peters, S. A. (2018). Smoking as a risk factor for lung cancer in women and men: a systematic review and meta-analysis. BMJ open, 8(10), e021611. http://dx.doi.org/10.1136/bmjopen-2018-021611

Yakubu, I., & Salisu, W. J. (2018). Determinants of adolescent pregnancy in sub-Saharan Africa: a systematic review. Reproductive health, 15(1), 1-11.

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SOAP Note Assignment
This SOAP Note should be written based on a 17 year old adolescent patient with alcohol and nicotine abuse.
Please this is a Master level paper and hence must be written by experienced professional PMHNP nursing paper writer only. Also be mindful of grammatical errors and plagiarism as there is zero tolerance for them. Please ensure the paper is not less than the number of pages paid for, which exclude cover and reference pages, as was the case with my last two paper orders. Please strictly adhere to the below stated rubric.

Overview
PMHNPs must document information to substantiate assessments, diagnoses, and plans of care. This facilitates safe patient care and appropriate transition management. In this assignment, you will create a SOAP note and discuss what you learned through a specific patient encounter.
Do not include any identifying patient information on your assignment.
Purpose
The purpose of this assignment is to facilitate the learner’s ability to create a comprehensive SOAP note.
Assignment outcome
At the conclusion of this assignment, the learner will be able to:
· Present a comprehensive SOAP note regarding a specific patient encounter.
· Identify a particular piece of learning that took place via this specific patient encounter.
Directions
Select a patient encounter in which you learned something new. Create a fully formed SOAP note regarding this patient encounter. Present a comprehensive SOAP note regarding a specific patient encounter with emphasis on a fully constructed plan of care including pharmacologic, therapeutic, and nonpharmacologic interventions for an adolescent with substance misuse.