Clinical Case Summary
Clinical Summary and Flow Chart
Substance Abuse History:
The patient’s is a thirty eight year old single woman. Her drug of choice is alcohol. She had her first drink at age 13 at which time she would sneak drinks at family gatherings and sometimes on the weekends with friends. At age 18 she started to drink more frequently and greater amounts, about 8-10 drinks, on each occasion. At times she would pass out. She noticed her drinking becoming a problem around the age of 28. She was drinking every night to “relieve stress” and sometimes missed working the next day because she was shaky and sick. Over the next two years she gradually increased the amount she drank from 1-2 bottles of wine a night to up to 3 and added shots of vodka. She noticed that she had to have a drink in the morning “even herself out”. She reports significant loss in appetite and weight loss of 20 pounds in the last three months.
The patient also reports being prescribed Clonazepam and taking it “mostly as directed”. She states that she would use alcohol while taking the prescription, often falling asleep while watching TV and not remembering getting into her bed.
Psychological functioning:
The patient has been diagnosed with depression and anxiety. At admission, the patient brought a prescription of Lexapro with her and asked that she be prescribed something for anxiety and sleep. During initial the mental health exam she appeared oriented to time, place and person, but was unsteady with her gate. She reported no history of hallucinations, delusions, suicidal ideology or homicidal thoughts. The patients appears lacking in insight regarding the seriousness and chronicity of her disease, focusing mainly on detoxing, getting some rest and getting relief from her symptoms of anxiety.
Educational/Vocational/Financial:
The patient completed high school and four years of college, graduating with a BA in Journalism. She has been working as a free-lance writer and
Substance Abuse History:
The patient’s is a thirty eight year old single woman. Her drug of choice is alcohol. She had her first drink at age 13 at which time she would sneak drinks at family gatherings and sometimes on the weekends with friends. At age 18 she started to drink more frequently and greater amounts, about 8-10 drinks, on each occasion. At times she would pass out. She noticed her drinking becoming a problem around the age of 28. She was drinking every night to “relieve stress” and sometimes missed working the next day because she was shaky and sick. Over the next two years she gradually increased the amount she drank from 1-2 bottles of wine a night to up to 3 and added shots of vodka. She noticed that she had to have a drink in the morning “even herself out”. She reports significant loss in appetite and weight loss of 20 pounds in the last three months.
The patient also reports being prescribed Clonazepam and taking it “mostly as directed”. She states that she would use alcohol while taking the prescription, often falling asleep while watching TV and not remembering getting into her bed.
Psychological functioning:
The patient has been diagnosed with depression and anxiety. At admission, the patient brought a prescription of Lexapro with her and asked that she be prescribed something for anxiety and sleep. During initial the mental health exam she appeared oriented to time, place and person, but was unsteady with her gate. She reported no history of hallucinations, delusions, suicidal ideology or homicidal thoughts. The patients appears lacking in insight regarding the seriousness and chronicity of her disease, focusing mainly on detoxing, getting some rest and getting relief from her symptoms of anxiety.
Educational/Vocational/Financial:
The patient completed high school and four years of college, graduating with a BA in Journalism. She has been working as a free-lance writer and