Demographic information
Name: unknown at this time
Age:
Sex: Male
Marital status: Single
Residence: unknown at this time
Occupation: Retired Veteran, Bill collector
Presenting problem
Alcoholism
Anxiety
Depression
History of presenting illness
Patient reports that he has been drinking for 27 years now. He reports that he experiences severe withdrawal symptoms if he does not drink. Such symptoms include tremors, anxiety, sweating, restlessness among others. He states that he drinks in order to deal with the excessive anxiety that he experiences. He says that he was physically and emotionally abused during his childhood by his father who was a drunkard until he was 12 years old that led to him developing PTSD which has been the cause of his anxiety.
Past Psychiatric history
Patient was diagnosed with depression a few years ago and he has been on antidepressants. He also reports to be struggling with insomnia for which he is also taking medicatons. He reports to be experiencing excessive anxiety which prompts him to engage in alcholism. He reports to experience visual hallucinations one day ago although this is the first time that this happened. He denies any suicidal ideations.
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Medical history
Patient reports that he had appendicectomy done in 2005. He also reports to have undergone surgery in Jne 2020 for a torn rotator cuff. He reports to be allergic to tetracycline as it causes him to have a generalized rash. He is curently taking lisinoprol 40 mg OD and HCTZ 20 mg OD for hypertension. He is also on Prozac 60 mg OD for depression. He is also on Trazodone 100 mg OD and seroquel 20 mg for insomnia. He is not on treatment for any othe chronic condition.
Substance use history
Patient has been abusing alcohol for 27 years now. He takes ½-3/4 of Fallon Vodka daily. He denies abusing any other substances although he states that he once smoked bang.
Developmental history
Patient reports that he grew up with both parents. His father was alcoholic and he used to abuse him physically until the age of 12 years.
Family Psychiatric history
Patient denies the existence of any mental health issues in the family although he states that his father was a chronic alcoholic. He also reports that one of the siblings uses some prescription medications although he is not sure they are for a mental illness.
Psychosocial history
Patient reports that he is a retired military man and 2 years ago he was working as a bill collector. He is single and has only one child who is aged 26 years old. He lives alone but he has been living with a friend for 8 months. He reports that by living alone, he experiences boredom that makes him to drink more. His father and mother are deceased. He says that his relationship with his siblings is strained. He does not report of any financial struggles. Patient reports that as a result of his alcoholism, he has lost touch with his hobbies such as watching football since a lot of time is spent imbibing alcool.
History of abuse/trauma
Patient reports that he grew up in an abusive family as his father used to physically beat him and this would cause his mother to yell which further traumatized him emotionally. He denies any history of being violent himself.
Review of systems
GIT- Normal appetitie, no dysphagia, no nausea, no vomiting, no diarrhea, no stomach pains/upset
CNS- complains of headache, normal vision, normal hearing, no dizziness
CVS- Reports of palpitations, no easy fatigability, no chest pains
RS- No cough, no chest pains, no difficulty in breathing
GUT- No dysuria, no frequency, no urgency, no hematuria
MS-No joint pains, no joint swelling, no reduced joint movements
Physical assessment
General exam- Patient is well dressed and his hair is well kempt. He is of good nutritional and hydration status. He has mild jaundice, no cyanosis, no parlour. His lips looked ulcerated. He has no finger clubbing and has no lymphadenopathy and no edema.
RS- he is not in respiratory distress, chest is symmetrical and moving with respiration, no obvious scars or swellings. Resonant note on all lung fields, tactile and vocal fremitus not increased. Vesicular breath sounds across all the lung fields.
CVS- warm peripheries, pulse rate of 80 bpm, JVP not raised, precordium not hyperactive, apex beat not displaced. S1 S2 heard without added sounds.
Abdomen- prominent veins, mildly distended, no obvious scars or swellings and no areas of tenderness. Has mild hepatomelgaly. Bowel sounds are normal.
CNS- Patient is alert, GCS 15/15, all cranial nerves are intact, normal muscle tone, power andd bulk. Normal reflexes.
Mental status exam
Patient is well groomed and is well oriented in time place and person. He is appropriately dressed for the occasion. His short term memory is intact although he has some issues with his long term memory. His thoughts are coherent and his speech is of normal volume and tone. He has good insight. The patient has problems concentrating however.
Differential diagnosis
Alcohol use Disorder
PTSD
Anxiety disorder
Bipolar disorder
Case formulation
Patient presents with a 27 year history of alcohol abuse. He reports that he experiences severe withdrawal symptoms if he does not drink for a period of time. He reports that he suffers from severe anxiety and depression which causes him to drink although he has tried to quit the habit without success. He suffered physical and emotional abuse when he was growing up. He is currently on treatment for depression, insomnia and hypertension. On examination, his mental status exam is normal but he has mild jaundice, ulcerated lips, prominent abdominal veins, mild hepatomegaly and ulcerated lips. His liver enzymes are elevated.
Treatment plan
Cognitive behavior therapy- The patient will be initiated on Cognitive behavior Therapy so that they can learn how their thoughts contribute to their drinking. In addition,the patient will be educated on ways to control their urge to drink. The patient will also be advised on how to alter their social environment in order to reduce the risk of relapse. CBT will also help the patient to cope with the anxiety that drives him into drinking.
Medical treatment with naltrexone- This drug will help reduce the urge to drink and thus reinforce the effects of cognitive behavior therapy.
