Clark is a 42-year-old Caucasian- Hispanic biracial

Clark is a 42-year-old Caucasian- Hispanic biracial male. He uses pronouns he, him, and his. He presents to the outpatient primary care office at the request of a follow-up by another provider in the office who only completes initial appointments. This follow-up was requested for secondary diagnosis with concerns for substance use disorder and depression. On initial screening at his primary care visit he endorsed that he drank 4Xs/week and that his consumption often was 3- 40 oz beers. Additionally, he endorses drinking 6 or more drinks in social situations at a minimum of 2Xs/ month. He endorses mood changes that started 4-6 weeks ago. He has had increased sadness and irritability since hurting his back at a barbeque. He endorses he was intoxicated and fell, twisting his back. He rates his pain at a 3/10 daily and occasionally a 6/10 if he moves anything heavy. Since the injury, he has missed work several days, has been placed on light duty and therefore has lost compensation. He works in the construction industry and notes “I have very little options when I can’t carry the shingles up the ladder or twist and turn all day-so I try to work a few days then I’m down for a couple and have to take time off again.” Score the AUDIT-Câ(Alcohol Use Disorders Identification Test (AUDIT) using the information provided. Based on Clark’s score, what is your next step? Briefly, what are pros and cons of using AUDIT-C vs. full AUDIT instrument? Differential Diagnosis, Rationale, Pertinent Positive, Negatives, DSM-5 Criteria On your initial interview you explore factors associated to his alcohol consumption.âThe discussion of substance use was introduced in a respectful and collaborative way.âAs his provider you start with the following: “I wonder if we might talk about your drinking today?â I do review these questions with all my patients as part of the initial appointment with me. I need to gain as much information as possible to best assist you.” Clark endorses the drinking has increased and is interfering with his relationships. He adds that he has been suffering from “awful lower back pain after falling down some stairs one evening at a friend’s barbeque after “drinking more than he usual.”â He reports having a hard time going to work as the pain has increased as has not went away on its own as anticipated. “I thought I would be sore for a few days then be fine.” â He states, “It has become some better but it’s still pretty bad.” “It has gotten to the point that I don’t really get out of the house as much and like I said I am missing a lot more work than ever before. I really am just laying around a lot and watching TV.” What are your preliminary differential diagnoses?â (minimum of 3) Provide rationale based on DSM-5 diagnostic criteria. What additional questions would you like to ask Clark to rule in or out the diagnoses you chose. Mental Status Exam General: A and O x4. Appearance, behavior speech appropriate. Thoughts coherent. Remote and recent memories intact. Appears stated age and of good health. Dressed appropriately for weather and situation. Movement: Wringing hands while talking, bounding leg at times, normal gait and stance; no involuntary movements. Speech: Speech was clear, organized, abundant. Mood: Notes recent changes in regular mood to irritable, depressed. Affect: Full ranging affect, correlates to mood described. Language: No language abnormalities; speech fluent; no dysphonia; no stuttering. Cognition: Patient-oriented x 4, no disorientation, short term memory impairment, reduced abstraction ability, diminished cognitive functioning, endorses concentration problems at work and at home due to chronic pain. Thought Process: No deficiency on evaluation of connectedness, organized. Thought Content: No thought content impairment; denies; suicidal ideation, homicidal ideations, paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, delusions, hallucinations. Insight and Judgment: Slightly impaired insight and judgment-indecisive on treatment options. Primary Diagnosis(es) Now that you have completed your assessment what is your primary diagnosis? Nonpharmacological Intervention Details: Motivational Interviewing As his PMHNP provider, you continue with the assessment process by inquiring about more details of the drinking. “Please tell me a bit more about what your drinking has been like over the past few years. Describe how you have increased in consumption amounts.”â Clark states that he had been a “regular drinker” since he was a teen. He was able to drink less early in his marriage and when his children were young, initially by request of his wife. He endorses an increase in drinking since the two oldest daughters went to college and are no longer living at home. He quickly adds that he has” tried to cut back but old habits die hard.” Next you inquire about withdrawal symptoms during times he tried to cut back. Clark denies any s/sx of withdrawal and reports “I never get shaky when I don’t drink” He denies history of seizures, or complicated withdrawal and reports that he “can see the benefit of cutting back” he just isn’t sure he “wants to stop drinking all together. It’s just always been my go-to- to calm down from stress.” You ask the following:â Tell me more about what your pain is like? How have you been dealing with it? How has it affected you and your family? Clark indicated that he has been feeling more discouraged by his back problems and wondered if he would ever feel like his old self again.â In addition to general feelings of hopelessness, Clark reports problems with sleep, poor concentration, irritability with his wife, and loss of appetite. He is also worried about finances.â He said “unless my back starts to get better soon, I don’t seek how I’m going to be able to support my family.â Thus far he had attempted to relieve his pain by increasing his alcohol consumption now using 5 – 6 beers per night and occasionally using Vicodin that he had obtained from a friend who had sustained an injury last year. Clark has mixed feelings about asking for help. He is also sensitive to the issue of his drinking and given the renewed request from his wife that he drink less, he is inquisitive about options. He reports that he has enjoyed drinking and felt it helped him manage the pain at night.â However, he also said that he had been falling asleep in front of the TV and waking up feeling stiff and unrested with his back hurting even more some mornings. Using the motivational interviewing technique of” developing discrepancy” how would you assist Clark to develop discrepancy between his desire to drink/ and the detrimental effects drinking has on his life? Include a general description of the technique you chose, an example of how you would use it in the interview with Clark. As his PMHNP provider, you ask Clark “Is it ok if I give you some information about the ways that alcohol can affect sleep.?”âClark nods and consents, and you gently explain how alcohol can affect sleep quality. You continue to build rapport by asking about Clark’s values and goals while remaining mindful of his social context, saying “I wonder if you could tell me a little more about your family and what plans you have in the next year or two?” Clark endorses the importance for him to be a positive role model for his adult children and that he wants to provide financially for his family by continuing to work. âHe reports that he has been worried about his relationship with his wife and the amount of money he is spending on alcohol. How would you use the motivational interviewing technique of rolling with resistance to assist Clark in increasing his readiness for change? Additional Components for Plan of Treatment At the end of the appointment, Clark agreed to have no more than 2 drinks per night and not to drink at all if his pain level was especially bad or worse than a 3/10 and he needed to take pain medication. He plans to follow through with an evaluation for physical therapy referred by the provider from the initial assessment on previous clinic visit for primary care of the pain. The previous provider also called in a script for Meloxicam 7.5 mg (may take one to two tabs daily as needed for pain). What is your initial treatment plan? You may include pharmacological and/or non-pharmacological interventions that you feel are appropriate. Please be specific about your recommendations.

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