Patient was apparently alright 20 years back when he started to take alcohol due to peer
influence. Beginning he use to consume only alcohol about 90 ml/day but frequency is increased as day
passed. Last drink is 15 days back and it was about 360 ml. Patient started to smoke cigarettes 16 years
...
CASE STUDY ON SUBSTANCE
USE (ALCOHOL, CANNABIS)
DISORDER CARE PLAN 9
,CASE STUDY
Identification data:
Name: Mr. Mahadevappa
Age/Sex: 40 y/male
Address: No-55, 5th cross, 1st main,
Doddabasthi, Mysore road,
Bangalore.
Education: 8th std
Occupation: Coolie
Income: 1,500/month
Marital Status: Married
Religion: Hindu
IP No NIMHANS
Informant: Patient and his wife, is adequate and reliable
Chief complaints:
History of alcohol consumption since 20 years
Cigarette smoking – 16 years
Occasional use of other drugs like Cannabis
Irritability, irrelevant talk, decreased sleep and reduced intake of food since 4 months
Talking to self
History of Present Illness:
Patient was apparently alright 20 years back when he started to take alcohol due to peer
influence. Beginning he use to consume only alcohol about 90 ml/day but frequency is increased as day
passed. Last drink is 15 days back and it was about 360 ml. Patient started to smoke cigarettes 16 years
back and initially he use to smoke 2-3 cigarettes per day, gradually number of cigarettes per day
increased and before admitting here number of cigarettes per day was 10-15. History of occasional use
of other drugs like cannabis is present. He was having craving, tolerance when he stops to take alcohol.
Patient is having complaints of sleeplessness, shaking of hands and lack of control since 3 years and
early morning drinking since 4 years. Patient is suspicious about his wife that she is having affairs with
other person.
, Precipitating factors – nil
Predisposing factors – nil
Biological functioning – decreased appetite and sleeping pattern and reduced personal hygiene
Occupational functioning – patient is not regular for his duty
Treatment history:
Mr. Mahadevappa is taking treatment for last 3 years for the same complaints. He had been
admitted in Govt hospital 2 years back for the complaints of pneumonia and took treatment for that. He
is presently receiving drugs like;
Inj. Lorazepam 2 mg 1-0-1
Tab. Risperidon 3 mg 1–0–1
Tab.Inac 50 mg 1-0-1
Past Psychiatric and Medical History:
Mr. Mahadevappa was admitted in Govt hospital for the complaints of pneumonia and he took
treatment for that, now he is alright. He is taking treatment for Substance use disorder sing 3 years and
for similar complaints he was admitted in same hospital 3 years back. No history of head injury,
convulsion and HIV.
Family History:
Patient is living with his wife and 4 children. History of substance use in the family is present.
His father was heavy drinker of alcohol. No other history of psychiatric disorders in the family.
Personal History:
Perinatal history: not known
Childhood history:
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