summer 2023 week 6 jornal

A 38-year-old male has presented to the clinic complaining of too much worrying concerning various issues. He states feeling easily fatigued, uncomfortable, trouble concentrating, muscle tension, sleep disturbance, irritability, and feeling of panic attack. He is currently on Ritalin 5mg PO after being diagnosed with ADHD as an adolescent, but he still feels that his mental condition is getting worse day by day. History of depression Hep C, anxiety, PTSD. The patient chief complaint is vague pain in his whole body and requesting prescription for Percocet and oxycontin. He was referred by a concerned friend to clinic. On the general appearance, he maintains good eye contact. Involved in interview. Linear thought process. He states that he is taking recreational medication, smoke heavily, and denied drinking at this time. he was previously taking 2 pints of vodka each day. VS with blood pressure is slightly increased and HR on 50’s. Toxicology screening is performed to figure out if the patient is taking other medications and stop any drug to drug interactions. Urine results were positive for fentanyl and benzodiazepine presumption.

Although pain is defined as a subjective experience upon observations patient did not display any major sign of pain. Question if he has medical seeking behavior. The patient become irritated when asked the reason for looking for opioid pain drug prescription. This behavior indicates that the patient has developed substance dependence that is “physiological adaptation” over time to the medication (Stahl, 2017). Furthermore, we must consider that SUDs and other psychiatric and medical condition happen comorbidly. We can cite anxiety, depression, attention-deficit hyperactivity disorder (ADHD), antisocial disorder amongst other, and post-traumatic stress disorder (National institutes of health, 2020).  Therefore, his feeling i]=of panic attack may be a antecedent to him seeking more drugs to self-meditate. His attitude towards substance use was discussed, readiness or willingness to change was assessed. He was recommended physical therapy for the management of his generalized muscle pain, considering his state of drug abuse, it would be safer to use non-opioids to treat his pain (Trasolini, McKnight & Dorr, 2018). 

He was therefore recommended to take over the counter Tylenol 975 mg every six hours. The patient was also given sertraline 25 mg PO and increased it to 50 mg maximum as required. Sertraline is a selective serotonin reuptake inhibitor (SSRIs) and has fewer major side effects and low chances of an overdose, including a lack of abuse potential (Stahl, 2017). Additionally, we provided addiction counseling, and in the occasion that he needed to give it a try, the benefit of having assistance in place to fight addiction. He states that he has friends in recovery and just required “to pick the 1000lb” phone and call them. Moreover, we explained about available resources such as rapid recovery coach in case things become intolerable for him. He unconditionally accepted the phone number. Accepted the plan as documented. He will continue with Ritalin 5 mg daily, Gabapentin 800 mg tab Wellbutrin 150 mg every 12 hours. He was given referral for physical therapy in order to manage muscle pain, and referral to addiction clinic.

References

National Institutes of health. (2020, April). National institute on Drug Abuse. The  Connection Between Substance Use Disorders and Mental Illness.  https://www.drugabuse.gov/publications/research-reports/common-  comorbidities-substance-use-disorders/part-1-connection-between-  substance-use-disorders-mental-illness

 Stahl, S. M. (2017). Stahl\’s essential psychopharmacology: Neuroscientific basis  and practical applications (4th ed.). Cambridge University Press.   

Trasolini, N. A., McKnight, B. M., & Dorr, L. D. (2018). The opioid crisis and the  orthopedic surgeon. The Journal of arthroplasty, 33(11), 3379-3382.

This visit aimed to assess critical issues that may have arisen and any progress within the timeline from the previous visit till now. It would help to ascertain the level of medication efficacy and advancement of ailment manifestation. After evaluation, the patient showed considerable attentiveness and focused with good coordination and general signs of normalcy. The patient was even actively engaging and expressing their feelings and thinking. The last visit was prompted by a distress call over mounting anxiety described as “mini panic attacks”, suggesting increased stressors. Upon further scrutiny, we realized a considerable upsurge in life events might contribute considerably to the patient’s stress levels. These include her workplace issues with the boss, parenting issues for a single mother, and the gain and loss of relatives, a roller coaster of emotional variation. Realizing that her newfound sister experienced the same mental challenges as her was intriguing and emotive.

           For the record, the patient denied abusing any mind-altering substances, including recreational drugs and alcohol. She also revealed no past traumas or issues with nutrition and weight. Reportedly, her Trazadone medication effetely gets her to sleep but with side effects of lethargy that discourage regular use. The same apprehension is held for her PRN Ativan medication unless in severe cases of panic attacks. Standard procedure was followed in assessing life stressors and coping mechanisms, validating feelings and thoughts, and discussing medication use. For medication, she was open to trying PRN Trazadone in case of an upsurge in anxiety, with the bedtime dosage maintained at 6 hours as required. Additional medication alternatives discussed with the patient were toward assisting with lessening anxiety and mood adjustment for more positivity. For this outcome, it was agreed that the patient would get on a Neurontin trial basis with support from a Zoloft prescription to help smoothen the experience. Neurontin is expected to supplement Zoloft and its impact, with the outcome being optimized anxiety symptoms. 100g of Neurontin will be good for a start, with risk and benefits analyzed for potential side effects and impactful results.

           On the first upcoming visit, there was general contentment with the positivity in her life with a new housing situation convenient for work, keeping her in good spirits. There were fewer panic attacks, and she showed openness to medication adjustments to include   PRN Ativan D/C even when using Neurontin with PRN Trazadone maintained while the Neurontin gets to work. The patient was actively involved and voiced comprehension with affirmed treatment plan approval.