Addiction Medicine Specialist - Initial Assessment Note

Initial Assessment Note Patient Identification: Sarah Jane Smith, 34 years old, Female, South African ID: 8901015000087, Hospital File No: HJH-234567. Referral Source: Family. Presenting Complaint: Patient reports feeling overwhelmed by her daily methamphetamine use, stating, "I can't stop using, even though I know it's destroying my life and my relationship with my children." Her primary goal is to achieve sobriety and regain custody of her two young children. She also expresses a desire to find stable employment. Substance Use History: Methamphetamine/Tik: Onset at age 28, duration 6 years. Currently using daily, approximately 1g per day, smoked. Last use: morning of 1 November 2024. Triggers: stress, social gatherings with friends who use. Social/Legal Consequences: lost job, lost custody of children, multiple arrests for possession. Previous attempts to stop: several unsuccessful attempts to cut down on her own, one 3-day detox at a community clinic 2 years ago, followed by rapid relapse. Alcohol: Social use until age 28, then occasional heavy episodic drinking when not using tik. Last use: 2 weeks ago (approx. 6 units). No significant problems related to alcohol. Cannabis/Dagga: Occasional use in her youth, ceased around age 25. No current use. Past Treatment and Relapse History: One previous detox admission to a community clinic 2 years ago for 3 days; however, she left against medical advice due to strong cravings. Relapsed immediately upon discharge, attributing it to returning to her previous living environment and peer group. No history of methadone or buprenorphine use. No psychiatric admissions. Medical and Psychiatric History: Medical: HIV positive, diagnosed 3 years ago, currently on Antiretroviral Therapy (ART) (Tenofovir/Lamivudine/Dolutegravir). Reports good adherence. No other chronic illnesses. No history of head trauma. Psychiatric: Diagnosed with Major Depressive Disorder 5 years ago, intermittently treated with citalopram in the past, but currently unmedicated. Reports symptoms of low mood, anhedonia, and feelings of worthlessness. No history of psychosis or PTSD. Medications and Allergies: Current Prescribed Medications: Tenofovir/Lamivudine/Dolutegravir (ART) once daily. Allergies: Penicillin (hives and rash). Physical and Mental State Examination: Vital Signs: BP 120/80 mmHg, HR 88 bpm, RR 16 bpm, Temp 36.8°C. Physical Findings: Appears thin, some dental caries. No track marks or signs of acute intoxication. Pupils equal and reactive to light. Mental State: Alert and cooperative. Appearance is unkempt. Speech is coherent, normal rate and volume. Mood reported as “depressed” and affect is congruent, constricted. Thought content reveals preoccupation with drug use and regret over past actions. No suicidal ideation reported today, but acknowledges past passive suicidal thoughts during periods of heavy use. Orientation: fully oriented to person, place, and time. Insight: partial, acknowledges drug problem but struggles with full understanding of its impact. Judgement: impaired, evidenced by continued drug use despite severe consequences. Risk Assessment: Overdose risk: moderate due to daily high-dose methamphetamine use. Withdrawal severity: expected to be mild to moderate, primarily psychological. No current suicidal ideation. No aggression or psychosis reported. Some cognitive impairment noted (difficulty with concentration). Housing insecurity (currently staying with a friend). Limited family support (estranged from parents). No history of harm to others. History of legal issues related to drug possession. Diagnosis: F15.20 Methamphetamine Use Disorder, Severe (ICD-10) F32.9 Major Depressive Disorder, Single Episode, Unspecified Severity (ICD-10) Z21 Asymptomatic Human Immunodeficiency Virus [HIV] Infection Status (ICD-10) Management Plan: Medical Stabilisation: Initiate outpatient methamphetamine withdrawal management, including supportive care and regular monitoring. Continue ART as prescribed, reinforce adherence. Psychiatric Care: Discuss re-initiation of antidepressant medication (e.g., Citalopram 20mg daily) and refer for psychiatric follow-up for depression management. Psychosocial Interventions: Refer to local addiction counselling services (e.g., Narcotics Anonymous, community-based support groups). Connect with social worker for assistance with housing and re-establishing contact with children. Harm Reduction: Educate on overdose prevention strategies. Follow-up: Schedule follow-up appointment in 1 week for re-assessment and medication review. Refer to inpatient rehabilitation programme upon stabilisation, contingent on bed availability.