Example Two
Patient Information
Name: Briana Jackson
Age: 27
Gender: Male
Ethnicity: African American
Date of Evaluation: 03/13/2023
Chief Complaint
“I feel like I can’t go a day without using cocaine. It’s really affecting my life, and I’m starting to worry about my health.”
History of present illness (HPI)
Briana Jackson is a 27-year-old African American male who presents with concerns about cocaine use. He reports that he has been using cocaine regularly for the past two years, with increasing frequency over the past six months. He reports using cocaine daily, and has attempted to cut back or stop using in the past, but has been unsuccessful. He reports feeling like he needs cocaine to function, and that his cocaine use has impacted his work, relationships, and overall functioning. He reports no significant past medical history and no other current medical concerns.
Mental Status Examination
Appearance: Briana is a well-groomed African American male, who appears alert and oriented.
Speech: Briana’s speech is clear and coherent, with no evidence of slurring or difficulty with articulation.
Mood/Affect: Briana’s mood is anxious, and his affect is dysphoric.
Thought Content: Briana reports feeling like he needs cocaine to function, and expresses concern about the impact of his cocaine use on his life.
Thought Process: Briana’s thought process is organized and goal-directed, with no evidence of tangential thinking or loose associations.
Perception: No evidence of perceptual disturbances.
Cognition: Briana is alert and oriented to person, place, and time. He reports no difficulty with memory or concentration.
Differential Diagnosis
- Cocaine use disorder
- Generalized anxiety disorder
- Major depressive disorder
To arrive at the primary diagnosis of cocaine use disorder, I considered several factors. Briana meets the DSM-5 criteria for cocaine use disorder, including a pattern of use that has persisted for more than 12 months, unsuccessful attempts to cut down or stop using, and impairment in social, occupational, and/or other areas of functioning. Additionally, Briana reports feeling like he needs cocaine to function, which is consistent with the diagnosis of a substance use disorder. Briana also reports anxious and dysphoric mood, which could suggest co-occurring anxiety or depressive disorders. However, these symptoms could also be secondary to the effects of cocaine use. While Briana meets the diagnostic criteria for both generalized anxiety disorder and major depressive disorder, these diagnoses are less likely given the context of his symptoms and the evidence of cocaine use disorder.
Reflection Notes
If I could conduct the session over, I would make sure to spend more time exploring the impact of Briana’s cocaine use on his relationships, work, and overall functioning. Additionally, I would try to better understand his motivation for seeking treatment at this time, and explore potential barriers to treatment engagement. In terms of legal/ethical considerations, I would make sure to discuss the risks and benefits of treatment options, including the use of medication-assisted treatment for cocaine use disorder. I would also consider factors such as Briana’s cultural background and socioeconomic status in developing a treatment plan that is appropriate for him. Finally, I would emphasize the importance of ongoing monitoring and support to prevent relapse and promote long-term recovery.