Case Discussion on Treatment of Opioid Use Disorder:
A 25-year-old Caucasian male presents to the outpatient detoxification and rehabilitation facility, for opioid and alcohol detoxification. For the past two weeks, this patient has being using 15 bags of heroin intravenously, two 48-ounces cans of beer, and has inhaled one hundred dollars’ worth of cocaine per day. According to the patient, the main reason for his seeking medical attention is to avoid going to jail. The patient has a history of law violations and has been monitored by a probation officer once a week. The probation officer worked with the patient and his family to arrange the probation treatment program instead of jail. The patient voluntarily agreed to be evaluated for admission to the outpatient treatment facility.
History
Mr. W is a 25-year-old single male who was referred for treatment by his probation officer. Mr. W is currently unemployed, and lives with his friends in a different location each day because his relationship with his family deteriorated due to addiction, he is no longer welcomed in the family house. According to Mr. W, he is not homeless “I always find a place to crash for a night”. Mr. W states that he has been using marijuana from age 15 but it is not his drug of choice any longer. He was introduced to heroin by his best friend about five year’s age during very stressful times in his undergraduate school. He states that his parents and two sisters are aware of his addiction problems and do not support him at all. However, his grandmother understands him more than anyone, and supports him financially in order to prevent him from stealing. Mr. W states that “If you do not admit me today, I will go and get high, and I do not care what happens to me after.”
History of present illness
Mr. W presents for opioid and alcohol detoxification and rehabilitation. He has no past medical history or any hospitalizations for medical conditions. However, he states that he was found unconscious by his mother in August 2016, and was hospitalized at Hospital due to a heroin overdose. He left the hospital against medical advice after two days of admission. He denies any history of head injury, trauma, asthma, hypertension, diabetes mellitus, or seizures. He is not on any prescribed medications. In addition, he denies any history of food, drug or latex allergies. Mr. W also denies any surgical history.
Psychiatric history
Mr. reports that he has struggled with severe anxiety and mild depression from an early adolescent age. He stated that he cannot remember the time when he was free of anxiety without using some kind of drugs. According to the patient, he was never hospitalized for anxiety or depression. However, he states that he did have suicidal ideations in the past, but not suicidal attempts. He denies any history of self-inflicted cuts or injuries. He has been prescribed benzodiazepine (Xanax) a medication for anxiety and seroquel, antipsychotic (an atypical type for depression, but stopped taking both medications two years ago. “I am not crazy and don’t want to be hooked on it.” Currently he is not under either a psychologist’s or psychiatrist’s care and does not take any psychiatric medication.
Review of systems
Mr. W reports that he was not feeling well, because he took his last bag of heroin at five in the morning. He denied recent visual changes, eye pain, discharge or inflammation. Denies a history of shortness of breath, wheezing, chest pain, or chest palpitations or arrhythmia. Mr. W states that he is very nauseous and had diarrhea in the morning, but denies abdominal pain. Mr. W is very restless, states that he has pain in his back, rated five out of 10 and just feels uncomfortable sitting in the chair although he denies a history of joint disease. Denies skin rash, moles, or changes in skin pigmentation. Denies any urinary incontinence, urgency or frequency. However, he states that his appetite has decreased during the past year and has been constipated for the past week. Denies use of any over-the-counter medications for his constipation.
Physical exam
Well-developed and nourished, slightly disheveled White male. Patient is alert and oriented to person, place, time and situation. Easily irritable, angry and very talkative. Vital signs are: BP 130/88 (left arm, sitting position) HR 104 RR 22 Temp. 98.8 Fahrenheit. Normocephalic, atraumatic, short hair and symmetric flushed face. Eyes: pupils are constricted bilateral, round, reactive to light and accommodation, sclera is red and teary. Ears with normal ear canal and tympanic membrane. Runny nose no erythema of nostrils and normal septum. Dry oral mucous membranes, poor dentations, and missing back tooth. Neck supple with midline trachea and no lymphadenopathy or jugular vein distention. Heart rate is regular but mild tachycardia (104), no murmurs, rubs or gallops, bilateral dorsalis pedis pulses 2+. Anterior and posterior lungs sounds are clear to auscultation bilateral, no wheezing, crackles or rhonchi. Bilateral upper extremities with multiple tattoos and fresh needle track marks in the antecubital area and popliteal space in the lower extremities. Bilateral hand tremors with extended arms, no edema noted on upper or lower extremities. Bilateral feet with dry, cracking and peeling skin, patient states that it is very itch at times. Bilateral toenails and fingernails with in normal limits, no cyanosis or clubbing of nails noted. In general, Mr. W is able to make his needs clear, however his speech is very rapid, and his pupils are constricted/pinpoint (1 mm).
· Summarize the clinical case.
· Create a list of the patient’s problems and prioritize them.
· Which diagnosis or diagnoses should be considered
· What is your rationale for the diagnosis or diagnoses
· What differential diagnosis should be considered
· What test or screening tools should be considered to help identify the correct diagnosis or diagnoses
· What treatment would you prescribe and what is the rationale (Consider psychopharmacology, diagnostics tests, referrals, psychotherapy, psychoeducation)
· What standard guidelines would you use to assess or treat this patient
references after 2019 minimun 2
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