Moderate alcohol use disorder Comprehensive SOAP Note Essay Example

Moderate alcohol use disorder Comprehensive SOAP Note Essay Example

The client provides verbal and written consent for the psychiatric interview and the treatment plan. The client can respond to the psychiatric questions and understands the psychiatric assessment, risks, and benefits. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Client ID: Initials: KL,AGE: 67, Demographic: African-American, Gender: M

Subjective.

Chief complaint: KL’s chief complaint is, “alcohol use is getting in the way of my marriage.” He says that “my drinking has increased over the last two years.” (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Source of reliability: Reliability of information is good. The client is an adult and in the right state of mind.

Present Illness: The client complains of inappropriate alcohol use that has increased over the past year. He admits that alcohol use is slowly affecting his marriage. He denies experiencing “shakes, buzz, or withdrawal” as before. KL notes that his wife is the biggest motivation to reduce alcohol consumption. The wife complains of KL being argumentative, irritable, and aggressive. He shouts at his children whenever they visit since they took his grandchildren away due to his aggressiveness and irritability. KL notes that he does not remember these incidents. He has fallen several times, and in the last episode, he broke his arm. KL denies being suicidal or homicidal. However, he often feels distressed and is unable to rescind his desire for alcohol “no matter how hard he tries.” KL admits to knowing the dangers of excessive alcohol consumption, including relationships with the wife, children, and grandchildren. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Current psych meds:  Chlordiazepoxide 5 mg QD BID for anxiety and insomnia. He reports increasing Chlordiazepoxide dosage to 10mg PO BID.

Past psychiatric history: No previous depressive episodes. No psychiatric diagnosis or hospitalization.

Past Medical Hx: No neurological, respiratory, cardiac, or endocrine issues. No seizures. No surgical history. Denies history of chronic problems. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Allergies: NKFDA.

Substance use/abuse: Chronic alcohol abuse.Denies use ofETOH or narcotic drugs.

Past family, social history: Married with four adult children (two women and two men), alive and well.Has had a healthy lifestyle. No legal trauma. No military background. Christian. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Family psych hx: None reported.

Education/Employment/Disability: Studied Military science with a speciality in tactical operations. Served as a tactical operator in the Army before joining fire service debarment.  No disability. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Primary support system: Wife and children.

Hobbies: Pool table.

Review of systems:

Constitutional: Reports weight loss. No fever or chills.

Eyes: No vision loss.

ENT: No change in hearing and sense of smell. No difficulty swallowing.

Cardiac: No chest pains or edema.

Respiratory: No cough or wheeze. Denies dyspnea.

GI: No abdominal pain. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Skin: No report of rash, lesions, or itchiness.

Neurologic: Reports blackout and knee weakness when intoxicated.

Endocrine: No polydipsia or polyuria.

Musculoskeletal: No joint pain or swelling.

Objective:

Vitals: BP: 115/70 P: 73 Ht: 6”0” Wt: 164 BMI: 22.2 Kg/m²

Appearance: Appropriately groomed.Maintains good eye contact.

Attitude/interaction: Appears withdrawn yet interactive.

Activity level/behavior: Warm with comments and behavior.

Orientation: Alert and oriented × 3.

Speech: Fluent and clear.

Thought content/process/perception: Resigned. No negative comments were noted.

Mood/affect: Mood describes as “resigned.”Mood and affect congruent. Judgment/insight/cognitive/memory: Good judgement and insight.Normal ability to abstract.

Attention: Maintains good attention and concentration. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Testing UDS negative.

Alcohol: Positive

Assessment:

1. Moderate alcohol use disorder (AUD). ICD-10 code is F1 0.20.  AUD symptoms presented by KL include consumption of larger amounts of alcohol, persistent desire to consume alcohol, and continued use of alcohol despite knowledge on social and interpersonal problems (American Psychiatric Association, 2013). This is the primary diagnosis. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)
2. Moderate sedative use disorder. ICD-10 code is F13.20. KL abuses Chlordiazepoxide, which is a sedative prescribed for anxiety and insomnia. Outcomes such as arguments with the spouse, impaired social life, and craving for more sedatives are documents as a diagnostic criterion for Sedative, Hypnotic, or Anxiolytic Use Disorder (American Psychiatric Association, 2013). This diagnosis is refuted. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)
3. Antisocial Personality Disorder. ICD-10 code is F60.2. KL symptoms are similar to individuals diagnosed with APD, such as irritability and aggressiveness (American Psychiatric Association, 2013). This diagnosis is refuted. APD diagnosis is only given when some behavioral symptoms are noted before age 15 and when behaviors disregard the rights of others. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)
4. Alcohol Intoxication. ICD-10-CM code is F10. 229. KL presents moderate comorbid AUD symptoms such as aggressive behavior and impaired social functioning that develops during or shortly after alcohol ingestion (American Psychiatric Association, 2013). This diagnosis is refuted.
5. Alcohol-induced depressive disorder.  ICD-10 code F10.24. KL symptoms include alcohol-induced depressive disorder, including impaired social functioning, depressed mood, irritability, and aggressiveness (American Psychiatric Association, 2013). This diagnosis is refuted. (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Plan:

Discontinue Chlordiazepoxide 5 mg QD BID for insomnia and anxiety due to addictions. Commence detoxification process for seven days. Start Gabapentin 600 mg orally two times a day to manage withdrawal. Start Disulfiram 500 mg daily to support treatment. Disulfiram is a safe and efficacious pharmacological treatment for alcohol dependence (Skinner et al., 2014).  Inpatient treatment is recommended to allow for intensive and effective management of detoxification (Zhu & Wu, 2018). Start outpatient Behavioral Couples Therapy for Alcohol Use Disorders (ABCT). ABCT is based on the assumption that intimate partners can reduce relationship distress, encourage abstinence and motivation to change drinking behavior (Klostermann, 2019). Join aftercare programs and groups for continuing support. Aftercare programs are crucial in managing relapses and cope with necessary life changes (Tracy & Wallace, 2016). (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Referral: Refer to an alcohol treatment specialist for Behavioral Couples Therapy for Alcohol Use Disorders using cognitive behavioral therapy after detoxification.

Next Visit: One week

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Inc.   (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Klostermann, K. (2019). Behavioral Couples Therapy for Substance Use Disorders. Social Behavior Research and Practice Open J, 3(1), 25-27. 10.17140/SBRPOJ-3-113 (Moderate alcohol use disorder Comprehensive SOAP Note Essay Example)

Skinner, M. D., Lahmek, P., Pham, H., & Aubin, H. J. (2014). Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis. PloS one, 9(2), e87366. https://dx.doi.org/10.1371%2Fjournal.pone.0087366

Tracy, K., & Wallace, S. P. (2016). Benefits of peer support groups in the treatment of addiction.(Moderate alcohol use disorder Comprehensive SOAP Note Essay Example) Substance abuse and rehabilitation, 7, 143. https://dx.doi.org/10.2147%2FSAR.S81535

Zhu, H., & Wu, L. T. (2018). National trends and characteristics of inpatient detoxification for drug use disorders in the United States. BMC public health, 18(1), 1-14. https://doi.org/10.1186/s12889-018-5982-8