Relapse or Crisis Encounter Note
Date and Nature of Presentation:
1 November 2024, 14:30. Patient self-presented to the clinic exhibiting signs of acute intoxication and distress, reporting a relapse after 3 months of sobriety. The acute event prompting review was a substance relapse involving multiple substances.
Substance Use:
Patient reported using crystal methamphetamine (tik) approximately 12 hours prior to presentation, estimated quantity of 0.5g, smoked. Also reported consuming 8 units of alcohol over a 4-hour period ending 2 hours prior to presentation. Triggers identified include recent job loss and an argument with his partner. Stressors related to financial difficulties and social isolation were also noted.
Risk Factors:
Identified risks include acute overdose risk due to polydrug use, impaired judgement, and potential for severe withdrawal given the recent alcohol and methamphetamine use. Patient denied suicidal ideation or attempts, aggression, or psychosis. No safeguarding concerns or risk to others were identified at this time.
Mental State:
Appearance: Dishevelled, poor hygiene, pupils dilated, tremulous.
Behaviour: Restless, agitated, irritable, poor eye contact.
Level of consciousness: Alert but disoriented to time.
Mood: Anxious, irritable.
Affect: Labile.
Thought content: Preoccupied with regret over relapse. No evidence of paranoia or hallucinations.
Insight: Partial insight into the impact of substance use but struggles with impulse control.
Judgement: Impaired, as evidenced by recent substance use.
Orientation: Oriented to person and place, disoriented to time.
Immediate Interventions:
* Medical stabilisation initiated: Vital signs monitored, offered oral rehydration.
* Brief counselling provided focusing on immediate safety and harm reduction strategies.
* Safety planning discussed, including securing a safe environment and identifying support persons.
* Engagement with family initiated to inform them of the situation and coordinate support.
Plan and Follow-Up:
* Referral to emergency department for comprehensive medical evaluation and acute withdrawal management due to polydrug use and potential complications.
* Discussion held regarding inpatient detoxification services; patient expressed openness to public sector rehabilitation.
* Follow-up appointment scheduled with community clinic addiction counsellor within 72 hours post-discharge from ED.
* Harm reduction measures discussed, including safer use practices and overdose prevention (naloxone education provided). Re-evaluation of mental state and withdrawal symptoms planned within 24 hours.
