Introduction to Software Engineering

53-year-old Puerto Rican Female Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing
problem.”
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
Decision Point One
Select what you should do:
Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
Antabuse (disulfiram) 250 mg orally daily
Campral (acamprosate) 666 mg orally three times/day
MY CHOICE FOR DECISION POINT ONE: Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal
region every 4 weeks
RESULTS FROM THE DECISION I MADE FOR 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 She is also still smoking, which has her concerned. She is also reporting some problems with anxiety,
which also has her concerned
RESULTS OF OTHER MEDICATIONS TO REFERENCE IN PAPER AS TO WHY THEY WERE NOT
CHOSEN: 
Results from Antabuse (disulfiram) 250 mg orally daily:
Client returns to clinic in four weeks
Mrs. Perez reports to the office complaining of sedation, fatigue, and a “metallic taste” in her mouth, which
“seems to be going away.” She also reports that she had just one drink about 5 days after starting the drug and
thought that she would “die.” She reports that her face was red, and she felt that her heart would “pound right
out of my chest.”
Mrs. Perez also reports that she continues to visit the casino but has not been spending as much money there.
She has noticed that her cigarette smoking is increasing
Results from Campral (acamprosate) 666 mg orally three times/day:
Client returns to clinic in four weeks
Upon return Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past
week, and it seems to be getting worse
She is also reporting that she is having “out of control” anxiety
Decision Point Two
Select what you should do next:
Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety
Refer to a counselor to address gambling issues
Add on Chantix (varenicline) 1 mg orally BID
MY CHOICE FOR DECISION POINT TWO: Refer to a counselor to address gambling issues
RESULTS FROM THE DECISION I MADE FOR 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.
RESULTS OF OTHER MEDICATIONS TO REFERENCE IN PAPER AS TO WHY THEY WERE NOT
CHOSEN:
Results from Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety:
Client returns to clinic in four weeks
Mrs. Perez reports that when she first received the Valium, it helped her tremendously. She states “I was like a
new person. This is a miracle drug!” However, she reports that she has trouble “waiting” between drug
administration times and sometimes takes her Valium early
She is asking today for an increase the Valium dose or frequency
Results from Add on Chantix (varenicline) 1 mg orally BID:
Client returns to clinic in four weeks
Client reports that she had to stop taking Chantix secondary to abnormal dreams and agitation
She also reports that she felt nauseous and vomited several times after she began taking the drug
Decision Point Three
Select what you should do next:
Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the
Gamblers Anonymous meetings 
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
MY CHOICE FOR DECISION POINT THREE: Explore the issue that Mrs. Perez is having with her counselor,
and encourage her to continue attending the Gamblers Anonymous meetings
RESULTS FROM THE DECISION I MADE FOR POINT THREE:
Guidance to Student
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.