Sample Case Study: Substance Abuse

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Substance History:
Mr. Fountain reports that he drinks alcohol infrequently. He estimated drinking less than 6 beers in the past month. He avoids mixing alcohol with his prescription pain medications. He quit smoking tobacco in 2001. Previously, he smoked 1 pack of cigarettes per day for approximately 10 years. He denied current and past use of illicit drugs or substances. He consumes 3 to 4, 500 ml bottles of caffeinated soft drinks per week.

On admission, Mr. Fountain complained of low back pain, ranging in intensity between 7 and 10, on a pain scale where 0 is no pain and 10 is the worst possible pain. He subjectively described this pain as a constant ache that permeates down into both legs, anteriorly and posteriorly, but can be stabbing, sharp, and burning at times. Sitting, standing, walking or lying down for prolonged periods of time can aggravate his back pain, while treatment modalities such as medications,
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Although he is obtaining approximately 8 hours of sleep each night, he still wakes up feeling unrefreshed in the morning. To combat feelings of exhaustion, he will nap in the afternoon for a duration of 2 hours, at least 3 times per week. He is prescribed CPAP therapy for sleep apnea which he uses nightly; however, he continues to struggle with gasping episodes during sleep, poor quality sleep, and daytime somnolence. In addition, several members of our Team did witness Mr. Fountain to be groggy during the education classes in week one of the program. Dr. Zacharias addressed his symptoms and advised to book an appointment with the sleep clinic to have the air pressure setting on his CPAP machine reevaluated. We reviewed the benefits of treating a sleep disorder including improved sleep quality that often leads to reduced pain perception and pain sensitivity as well as less daytime

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