This journal is about a family that I have interact with during my practicum at Community Behavioral Health Center in Fresno, California. Per Walden University’s policy, the patient will refer to patient L who is the husband and patient P who is the wife. A genogram of this family will also be presented at the bottom of the assignment.
Demographic information
Patient L and P have been together for 15 years and married for 10 years. Both couples are Mexican- American, Patient L worked as a teller for Bank of America, lost his Job roughly one year ago after a traumatic motor vehicular accident that left him with a right above knee amputation. He was hospitalized for months due to an infection at the amputation site and unable to fit to a prosthetic leg, so he is mobilizing with a wheelchair. His wife P is a manager at a local Drug Store. This particular family is considered to be a middle-class family, they reside in suburban area in Clovis, California. They have three children, twin boys ages 15 and a daughter age 12.
Presenting problem
“I am can’t deal with husband any more, all he does is abusing drugs and drinks all day and nights. I think the only way to be free is by leaving him, unless he stops drinking”.
History or present illness
Patient L has been abusing ETOH, Ativan and Percocet the past year, following his traumatic accident.
Recent psychiatric history– Post the accident, patient L was diagnosed with Post traumatic stress disorder (PTSD), and General Anxiety disorder, and depression. He was prescribed Ativan for his anxiety and to help him rest at night. The patient prescribed Percocet post discharge at the hospital and remain Percocet for pain.
Medical history
Mr. L has hypertension, MRSA infection to right stump, and right above knee amputation. His wife denies having any past medical history.
Substance use history
Patient L became addicted to Ativan, Percocet, and started to drink alcohol since the traumatic accident. His wife stated prior to the accident, he was a binge drinker, but only drinks wine. Currently Mr. L drinks Jack Daniel every day, and just started smoking cigarettes the last three months.
Developmental history–
none reported
Family psychiatric history
Both parents deny having any family mental illness in their family
Psychosocial history– ETOH and substance abuse such as Ativan, Percocet. Wife denies any ETOH or substance abuse history
History of abuse and trauma– both deny any history of abuse, but Mr. L did suffer a traumatic injury during the car accident.
Review of systems:
HEENT-Both Deny problem with vision, hearing loss,
Cardiovascular systems- deny any weight gain, deny having any edema, deny having chest pain, palpitation. Mr. L has hypertension, but it is control with 10 milligrams of Amlodipine daily. His wife denies having any cardiac issues.
Gastrointestinal (GI)- they both deny having any history of constipation or diarrhea, but Mr. L reported to have low appetite but most likely due to his alcohol abuse.
Genitourinary (GU)- Both deny any issues with urination. Mr. L loss interest in having sexual intercourse with since his accident.
Musculoskeletal- Mr. L has a right AKA, and still suffers from phantom pain. His wife denies having any musculoskeletal related issues, but stating she is just tired all the time.
Neurologic- Mr. L denies having any headache, blurry vision, but still have phantom pain, denies having numbness and tingling. His wife denies having any neurological issues with the exception of a slight headache from time to time which she scores 3 out 10 on the 1-0 numerical Psychiatric – Mr. L diagnosed with PTSD, depression and substance abuse post his traumatic accident. His wife denies any mental health issues, but stated it is sad to see the man she married, and the father of her children turned to drugs and alcohol. Both deny having any suicidal or homicidal ideation.
Assessment
- Physical assessment- No head to toe assessment performed on both patients. However, Mr. L appeared to be anxious, tearful because he missed being on his two legs and miss working and be a man to support his family. He stated he can not have a prosthetic leg, he has to rely on his wheelchair to get around, and it even hard for him to do his ADL’s. Both couples dress appropriate for the season.
- Mental status exam: Appearance- Mr. L is 6 ft 2” weight 163 pounds, appear to be frail and malnourished, unable to sustain eye contact and when he does, he is very tearful, slightly agitated. Both patients were alert, dress suitably for the occasion, wife answer all question appropriately during the assessment, but husband was agitated and tearful at times.
Mr. L thought process was coherent, with a low volume with the exception of his sparring agitation to certain questions. Patient was blunt but became flat affect when mentions his children.
Cognitive examination- both patients are alert, oriented time four but husband is slightly agitated. His wife mentioned he was a very intelligent man, prior to his drinking and drug abuse issues. Patient has a hard time with his short-term memories, it has been hard for him to carry on a decent conversation, even though he was coherent during the assessment.
Differential diagnosis
- Alcohol abuse disorder- Alcohol abuse is one of the most critical problem many individuals are facing throughout the world. In the United States, excessive alcohol intake lead to nearly a million death per year (Maremmani et.al2016). Mr. L scored 80 percent in the AUDIT screening assessment, which indicated he is severely depending on alcohol.
- PTSD- is categorized by groups of signs and symptoms that result from a life-threatening experience or perceived a circumstance that imperil an individual’s life or others in their surroundings. Posttraumatic stress disorder symptoms include re-living the event that lead to the condition. An individual might feel total body numbness, emotional impartiality, agitation, and confusion (Arbona, & Schwartz, 2016)
Case formulation
- Presenting problem- couple presented but the husband is suffering from ETOH and substance abuse such as Ativan and Percocet. Per the DSM V, the patient is diagnoses of alcohol abuse disorder. Mr. L predisposing factor was the traumatic motor vehicular accident which left him with a right AKA, unable to obtain a prosthetic leg, and loss his job, and unable to locate another place of employment. His wife is his support system, but she is tired of his drug and ETOH habit. The wife unable to handle him, she is thinking about leaving him. Decisive factor- the patient stated he still loves his family, and his wife mentioned she still loves her husband, but she can no longer his drug and alcohol habits. The wife gives him the ultimatum of getting help via a local rehabilitation center. patient’s wife appears to love her husband and would like for him to attend rehab or treatment of some sort. Per the wife his parents are still involve in his life, in fact lives two doors down from them. His parents help with the children, and afraid if his wife leaves him, he will try to commit suicide.
Treatment plan
The patient said he will do anything to lose his family, he has agreed to participate an intensive outpatient treatment five days a week at a local rehabilitation center. Since he has not driven since the accident, his wife will drop him off on her way to work and his parents will pick him up after each session every day. The program will last 30 days. The patient also agrees to participate in the 12 steps program and join a drug and alcohol anonymous program. The plan is to titrate down his Ativan until discontinue in a month period. Replace Ativan with Vistaril 25 milligrams PRN daily not to exceed 4 doses in a 24-hour period. The patient was also prescribed naltrexone 50 milligrams daily for 14 days. Naltrexone is an agent that blocks opioid receptors, predominantly the mu-opioid receptor (Anton, 2008). According to Anton (2008), in random research study to assess the effectiveness of naltrexone hydrochloride in individual who depends on alcohol, it was decided that naltrexone was very effective with a combination of another therapy.
Conclusion
Problem do arise within family. The patient is lucky to have his entire family involved in his care. if participated in the program as agreed, and with the help and support from his family. The patient expects to recover from his drug and alcohol abuse problem. As a future mental health care provider, it is significantly important to be acquainted with a comprehensive assessment; Comprehending this type of assessment will help simplify understanding of diagnoses, care plan and treatment for individualized patient.