MENTAL STATUS EXAM
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female who is alert, 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. As 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 & self-reported mood. She visual or auditory hallucinations, 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
Decision Point One
Antabuse (Disulfiram) 250 mg orally every morning ON
Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
Antabuse (Disulfiram) 250 mg orally daily
Campral (Acamprosate) 666 mg orally three times/day
E
· Client returns to clinic in four weeks
· Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse
· Clientis She is also reporting that she is having “out of control” anxiety..
Decision Point Two
RESULTS OF DECISION POINT TWO Decision Point Two
Select what the PMHNP should do next:
Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety
Refer to a counselor to address gambling issues
Add on Chantix (varenicline) 1 mg orally BID
- Client returns to clinic in four weeks
- Mrs. Perez reports that when she first received the valium, it helped her tremendously. She states “I was like a new person- this is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her valium early. She is asking today for you to increase the valium dose or frequency
- Although she reports that her anxiety is gone, she still reports suicidal ideation, but states “with that valium stuff, who cares?”;;;;;;;;
- Decision Point Three
- Add on Wellbutrin (bupropion) XL 150 mg orally daily
- Guidance to Student
