Puerto Rican Woman
Case study: A Puerto Rican Woman with Comorbid Addiction (ETOH and
Gambling)
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
Results of the interactive exercise:
Decision point One:
I chose to start the patient with Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the
gluteal region every 4 weeks, over Antabuse (Disulfiram) 250 mg orally daily or Campral
(Acamprosate) 666 mg orally three times/day.
Results of the decision point one:
• Client returns to clinic in four weeks.
• Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since
receiving the injection.
• Client reports that she has not been going to the casino, as frequently, but when she does
go, she “drops a bundle” (meaning, spends a lot of money gambling)
• Client reports she is also still smoking, which has her concerned. She is also reporting
some problems with anxiety, which also has her concerned.
Decision point two:
I chose to continue current medication and to refer the patient to a counselor to address gambling
issues over adding on Valium (Diazepam) 5 mg orally TID/PRN for anxiety or adding on
Chantix (Varenicline) 1 mg orally BID.
Results of the decision point two
• Mrs. Perez returns in 4 weeks and reports that the anxiety that she had been
experiencing is gone.
• She reports that she has met with the counselor, but she did not really like her.
• She also started going to a local meeting of Gamblers Anonymous. She states
that last week, for the first time, she spoke during the meeting. She reports
feeling supported in this group.
Decision point three:
I chose to continue the current dose of Naltrexone and explore the issues that Mrs. Perez is
having with her counselor and encourage her to continue attending the gamblers anonymous
meetings. I did not select to encourage Mrs. Perez to continue seeing her current counselor as
well as continuing with the gamblers anonymous Group or to discontinue Vivitrol and encourage
Mrs. Perez to continue seeing her counselor and to continue participating in the gambling
anonymous group.
Guidance to Student of decision point three
Although controversy exists in the literature regarding how long to maintain a client on Vivitrol,
8 weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse
practitioner should explore the issues that Mrs. Perez is having with her counselor. As will be
covered in more depth in future courses, ruptures in the therapeutic alliance can result in clients
stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the
gambling problem spontaneously remitting is lower (than had the client continued to receive
therapy). Recall that there are no FDA-approved treatments for gambling addiction. The
mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived
support from the Gamblers Anonymous meetings, she should be encouraged to continue her
participation with this group.
You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of
addictions, and to enhance her overall health.
Instructions:
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.
Decision #1 (1 page)
1- Which decision did you select?
2- Why did you select this decision? Be specific and support your response with clinically
relevant and patient-specific resources, including the primary literature.
3- 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.
4- 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).
5- Explain how ethical considerations may impact your treatment plan and communication
with patients. Be specific and provide examples.
Decision #2 (1 page)
1- Why did you select this decision? Be specific and support your response with clinically
relevant and patient-specific resources, including the primary literature.
2- 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.
3- 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).
4- Explain how ethical considerations may impact your treatment plan and communication
with patients. Be specific and provide examples.
Decision #3 (1 page)
1- Why did you select this decision? Be specific and support your response with clinically
relevant and patient-specific resources, including the primary literature.
2- 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.
3- 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).
4- Explain how ethical considerations may impact your treatment plan and communication
with patients. Be specific and provide examples.
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 patientspecific resources, including the primary literature.
Please make sure all questions are answered entirely, use APA 7 and please provide
plagiarism free paper.
Thank you
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