CASE NO.

4: Case taking using Foundation of Addiction Management 2019

Patient Case Presentation Performa Template:

Case Presenter: Clement Lallawmzuala Date of Presentation: 18/05/23

Reasons for Presentation

 Help with diagnosis: YES

 Help with medication: YES

Patient’s reason for seeking treatment

Associated decreased sleep, tremor, weakness, reduced concentration, reduced appetite,

and restlessness.

Background (Demographic details of the Patient)

Name: Mr. L

Age: 44 years; Gender: M; Education: B.A

Marital Status: Divorced (1 child)

Socioeconomic Status: Middle; Place: Urban

New Case: Yes

Informants: Patient

Complaints with Duration of each Complaint

 Severe withdrawal symptoms (72 hours)

History of present illness

Onset: Acute

Course: Episodic

Duration: 17 years
 Predisposing factors: Peer influence

Precipitating factors: Loneliness from Divorce (Marital problem)

Perpetuating/ Maintaining factors: Dopamine rush ( State of Euphoroa)

Substance Use History:

Substances Quantity Route Frequency Duration Last Use

Tobacco 1 Box Smoking 2 days 17 Present
Opioid & 2 full red Chest& Everyday 17 1 month
Injecting Drugs caps Injection ago

Withdrawal symptoms in past or now:

 Sweating

 Insomnia

 Appetite loss

 Cannot withhold information for a long period of time

Depression Mania Anxiety Psychosis

Sadness of mood Distractibility Trauma
Insomnia/hypersomnia
Loss of Energy
Reduced appetite
Irritability
Duration:17 years Duration:17 years Duration: 2004 Duration:
Any Treatment history: NO YES
NO Surgery

Psychiatry Symptoms experienced by the subject

Summary of History of both Substance Abuse and Psychiatric problems

The pnt is a 44-year-old Male who started using these substances in 2007 starting with
opioid and other injecting drugs followed by tobacco through chesting and injection . The
pnt was influenced to start these substances form his peers. The exact reason which made
the pnt start using these substances was the feeling of loneliness from not being with his
wife and child because of their divorce. However, the pnt’s take on why he kept abusing
these substances was because of the euphoric feeling.

The pnt’s psychiatric symptoms started after he tried to be free of the substances.

Any comorbid illness

 Difficulty in self-acceptance

 Societal neglect
Past History:

Psychiatric Co-morbid illness: Triggers

Medical Comorbid illness: YES

Hepatitis C and Diabetes

Family Psychiatric History: None

History of Psychiatric/Medical/Surgical illnesses- NO

Family Relationship:

The Pnt wishes that his mother provides more love towards him. His family views his abuse
as an illness that can be cured and provides financial support as much as they can.

Personal History:

Educational level: B.A

Marital status& Number of children: Divorced with 1 child

Occupational history: Used to be a Teacher

Social relationship: Was very involved in Y.M.A and religious statuses but withdrew from all
of these after using the substances
Premorbid history: Calm and collected

General Examination:

Pulse: 97/99

Mental Status Examination (MSE):

General Appearance & Behavior: Well-groomed and kempt

Eye to eye contact: Maintained except when family relation is discussed

Rapport; Established easily

Psychomotor activity: Normal

Speech: Normal

Thought: No delusion

Mood: ”I’ m fine”

Non-pharmacological Interventions tried:

INTERVENTION TRIED? HELPFUL?

Psychoeducation Yes No
Motivational Interviewing Yes Yes
Relaxation Strategies Yes Yes
Others (Describe) No No