Scenario: 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 two years, she has been

having more and more difficulty maintaining her sobriety since they opened the new "Rising Sun" casino

near her home. Mrs. Perez states that she and a friend went to visit the new casino during their 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 two 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 that 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 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 has borrowed over $50,000 from her retirement

account to pay off her gambling debts. She is very concerned because her husband does not know that

she has spent this much money.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert, 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. As 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 & self-reported mood.

She visual or auditory hallucinations, 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

Decision Point One:

Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks (Chosen )

Decision Point Two: Refer to a counselor to address gambling issues (Chosen)

Four Weeks

Client reports that the anxiety that she had been experiencing is gone

Client reports that she has met with the counselor, but did not really like her. She did start going

to a local meeting gamblers anonymous. She stated that last week, for the first time, she spoke

during the meeting. She reports feeling supported in this group

Decision Point Three

Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the

Gamblers Anonymous group

Discontinue Vivitrol. Encourage Mrs. Perez to continue seeing her counselor and to continue

participating in the Gamblers Anonymous group

Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetings(Chosen).

Questions (details please)

• Why did you select this decision (Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetings (Chosen))? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• 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.
• What were you hoping to achieve by making this decision?
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.