BACKGROUND
Mrs. Maria Perez is a 53 year old Puerto Rican
female who presents today due to a rather “embarrassing problem.”
SUBJECTIVE
Mrs. Perez admits that she has had “problems” with
alcohol since her father died in her late teens. She reports that she has
struggled with alcohol since her 20’s and has been involved with Alcoholics
Anonymous “on and off” for the past 25 years. She states that for the past 2
years, she has been having more and more difficulty maintaining her sobriety
since the opening of the new “Rising Sun” casino near her home. Mrs. Perez
states that she and a friend went to visit the new casino during its grand
opening at which point she was “hooked.” She states that she gets “such a high”
when she is gambling. While gambling, she “enjoys a drink or two” to help calm
her during high-stakes games. She states that this often gives way to more
drinking and more reckless gambling. She also reports that her cigarette
smoking has increased over the past 2 years and she is concerned about the
negative effects of the cigarette smoking on her health.
She states that she attempts to abstain from
drinking but she gets such a “high” from the act of gambling that she needs a
few drinks to “even out.” She also notices that when she drinks, she doesn’t
smoke “as much,” but she enjoys smoking when she is playing at the slot
machines. She also reports that she has gained weight from drinking so much.
She currently weights 122 lbs., which represents a 7 lb. weight gain from her
usual 115 lb. weight.
Mrs. Perez is quite concerned today because she
borrowed over $50,000 from her retirement account to pay off her gambling
debts, and her husband does not know.
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female
who is alert and oriented to person, place, time, and event. She is dressed
appropriately for the weather and time of year. Her speech is clear, coherent,
and goal directed. Her eye contact is somewhat avoidant during the clinical interview.
When you make eye contact with her, she looks away or looks down. She
demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported
mood is “sad.” Affect is appropriate to content of conversation and
self-reported mood. She denies visual or auditory hallucinations, and no
delusional or paranoid thought processes are readily appreciated. Insight and
judgment are grossly intact; however, impulse control is impaired. She is
currently denying suicidal or homicidal ideation.
Diagnosis: Gambling disorder, alcohol use disorder
Introduction to the case (1 page)
Briefly explain and summarize the case for this
Assignment. Be sure to include the specific patient factors that may impact
your decision making when prescribing medication for this patient. ( The
response accurately, clearly, and fully summarizes in detail the case for the
Assignment.
The response accurately and clearly explains in
detail the specific patient factors that impact decision making when
prescribing medication for this patient.)
Decision #1 (1–2 pages)
• Which decision did you select?
• Why did you select this decision? Be specific
and support your response with clinically relevant and patient-specific
resources, including the primary literature.
• Why did you not select the other two options
provided in the exercise? Be specific and support your response with clinically
relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this
decision? Support your response with evidence and references to the Learning
Resources (including the primary literature).
• Explain how ethical considerations may impact
your treatment plan and communication with patients. Be specific and provide
examples. (The response accurately and clearly explains in
detail the decision selected.
The response accurately and clearly explains in
detail why the decision was selected, with specific clinically relevant
resources that fully support the decision selected.
The response accurately and clearly explains in
detail why the other two responses were not selected, with specific clinically
relevant resources that fully support the response.
The response accurately and clearly explains in
detail the outcome the student was hoping to achieve with the selected decision,
with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in
detail how ethical considerations impact the treatment plan and communication
with patients.
Examples provided fully support the decisions
and responses provided.)
Decision #2 (1–2 pages)
• Which decision did you select?
• Why did you select this decision? Be specific
and support your response with clinically relevant and patient-specific
resources, including the primary literature.
• Why did you not select the other two options
provided in the exercise? Be specific and support your response with clinically
relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this
decision? Support your response with evidence and references to the Learning
Resources (including the primary literature).
• Explain how ethical considerations may impact
your treatment plan and communication with patients. Be specific and provide
examples. (The response accurately and clearly explains in
detail the decision selected.
The response accurately and clearly explains in
detail why the decision was selected, with specific clinically relevant
resources that fully support the decision selected.
The response accurately and clearly explains in
detail why the other two responses were not selected, with specific clinically
relevant resources that fully support the response.
The response accurately and clearly explains in
detail the outcome the student was hoping to achieve with the selected
decision, with specific clinically relevant resources that fully support the
response.
The response accurately and clearly explains in
detail how ethical considerations impact the treatment plan and communication
with patients.
Examples provided fully support the decisions
and responses provided.)
Decision #3 (1–2 pages)
• Which decision did you select?
• Why did you select this decision? Be specific
and support your response with clinically relevant and patient-specific
resources, including the primary literature.
• Why did you not select the other two options
provided in the exercise? Be specific and support your response with clinically
relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this
decision? Support your response with evidence and references to the Learning
Resources (including the primary literature).
• Explain how ethical considerations may impact
your treatment plan and communication with patients. Be specific and provide
examples. (The response accurately and clearly explains in
detail the decision selected.
The response accurately and clearly explains in
detail why the decision was selected, with specific clinically relevant
resources that fully support the decision selected.
The response accurately and clearly explains in
detail why the other two responses were not selected, with specific clinically
relevant resources that fully support the response.
The response accurately and clearly explains in
detail the outcome the student was hoping to achieve with the selected
decision, with specific clinically relevant resources that fully support the
response.
The response accurately and clearly explains in
detail how ethical considerations impact the treatment plan and communication
with patients.
Examples provided fully support the decisions
and responses provided.)
Conclusion (1 page)
• Summarize your recommendations on the
treatment options you selected for this patient. Be sure to justify your
recommendations and support your response with clinically relevant and
patient-specific resources, including the primary literature. (The
response accurately and clearly summarizes in detail the recommendations on the
treatment options selected for this patient.
The response accurately and clearly explains a
justification for the recommendations provided, including clinically relevant
resources that fully support the recommendations provided.)
Last Completed Projects
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