[ANSWERED 2023] Assignment Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Written By: Dan Palmer, RN

Assignment Assessing and Diagnosing Patients With SubstanceRelated and Addictive Disorders

Assignment Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
Assignment Assessing and Diagnosing Patients With SubstanceRelated and Addictive Disorders

An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society.

Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.

For this Assignment you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background.

To Prepare:

  • Review this week’s Learning Resources and consider the insights they provide.
  • Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
  • By Day 1 of this week select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Identify at least three possible differential diagnoses for the patient.

By Day 7 of Week 8

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

RUBRIC

  • Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
  • In the Subjective section, provide:
    • Chief complaint
    • History of present illness (HPI)
    • Past psychiatric history
    • Medication trials and current medications
    • Psychotherapy or previous psychiatric diagnosis
    • Pertinent substance use, family psychiatric/substance use, social, and medical history
    • Allergies
    • ROS
  • In the Objective section, provide:
    • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
    • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
  • In the Assessment section, provide:
    • Results of the mental status examination, presented in paragraph form.
    • At least three differentials with supporting evidence. List them from top priority to least priority.
      • Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis.
      • Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
  • Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
  • Written Expression and Formatting—Paragraph development and organization:Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
  • Written Expression and Formatting—English writing standards:Correct grammar, mechanics, and punctuation

TRANSCRIPT OF VIDEO FILE: 

00:00:00______________________________________________________________________________

00:00:00  BEGIN TRANSCRIPT:

00:00:00  [sil.]

00:00:20  LISA Well I had to be here in this hospital if that answers your question.

00:00:25  OFF CAMERA Yes, thank you. Can I get you a drink of water or something else to drink? Anything?

00:00:35  LISA A drink isn’t going to convince me, right? You’re going to have to convince me.

00:00:40  OFF CAMERA What is you want me to persuade you to do?

00:00:45  LISA Going to rehab.

00:00:50  OFF CAMERA What worries you about going to rehab?

00:00:55   [sil.]

00:01:00 LISA Everything.

00:01:00 OFF CAMERA Okay. I tell you what let’s go back a little bit and tell me about how you’re feeling today.

00:01:10 LISA Scared.

00:01:15 OFF CAMERA Can you tell me more about that feeling of being scared?

00:01:20 LISA Well, I don’t want to be. I don’t want to be what people say I am because if I say it and I’m not going to say it because I ain’t going to change. I can’t.

00:01:35 OFF CAMERA What do people say you are?

00:01:40 LISA And I’m not.

00:01:45 OFF CAMERA What don’t you want to be?

00:01:45 LISA An addict.

00:01:50 OFF CAMERA Do you use drugs and alcohol?

00:01:50 LISA Yeah sometimes I have a drink. You know with friends [inaudible] but it doesn’t matter. I’m in control.

00:02:00 OFF CAMERA Do you feel in control now?

00:02:05  LISA Maybe I could just get that drink [inaudible].

00:02:10  OFF CAMERA Sure. Sure. Here you go.

00:02:15  LISA Thank you.

00:02:20  [sil.]

00:02:30  LISA You know what I just think I should leave.

00:02:30  OFF CAMERA You keep saying you should leave. You said that earlier but do you really want to leave?

00:02:40  LISA No.

00:02:45  OFF CAMERA Okay. Tell me why you are here.

00:02:45  LISA Because I’m scared.

00:02:50  OFF CAMERA You said that earlier. You think if you could — then I could figure out together why you’re scared and maybe we can come up to a plan. Up with a plan and if we do that, then maybe your fears will disappear.

00:03:05  LISA No not these fears [inaudible] because it’s over.

00:03:10  OFF CAMERA What’s over?

00:03:10  LISA Everything. The business.

00:03:15  OFF CAMERA What do you mean?

00:03:20  LISA Jeremy.

00:03:25  OFF CAMERA Who is Jeremy?

00:03:25  LISA He’s my boyfriend. I saw him naked with Alisa [assumed spelling] with the same fucking name as me. We now have the same fucking boyfriend. In my office, he was screwing that fucking cunk.

00:03:45  OFF CAMERA So you’re the one who caught Jeremy cheating?

00:03:55  LISA Yeah. Cheating? Yeah that’s a clever word shrinks use.

00:04:05  OFF CAMERA So you and Jeremy share an office?

00:04:05  LISA Yeah we do commercials for local businesses, you know, build websites, that kind of stuff. We started a business together. He moved in with me.

00:04:15  OFF CAMERA How long ago was that?

00:04:20  LISA Nine months.

00:04:20  OFF CAMERA Do you have any children?

00:04:20  LISA Not with that fucking asshole.

00:04:25  [sil.]

00:04:30  LISA I have a daughter, Sarah. Gosh, she’s beautiful. She stays with some friends. She’s not related to Jeremy, thank God.

00:04:45  OFF CAMERA And where are you staying?

00:04:45  LISA I’m renting a place far away from here. You know I ran down to the bank to empty both our bank accounts.

00:04:55  OFF CAMERA Business accounts?

00:04:55  LISA Yeah. And do you know that asshole has been draining them for 4 months? I swear.

00:05:05  OFF CAMERA Taking money out of your account without your knowledge.

00:05:05  LISA Yeah. For his buys.

00:05:10  OFF CAMERA Buys?

00:05:10  LISA Yeah, to payoff his debts with my money.

00:05:20  OFF CAMERA Or crack cocaine?

00:05:25  LISA Yeah for crack.

00:05:25  OFF CAMERA How long have you know he’s been smoking crack?

00:05:30  LISA Ever since I saw him with that — every since I saw with her naked. The both of them naked.

00:05:40  OFF CAMERA What was that like seeing Jeremy and Alisa naked and smoking crack?

00:05:40  LISA Well have you ever seen someone you love naked smoking crack?

00:05:45  OFF CAMERA No.

00:05:50  LISA Yeah no I didn’t think so.

00:05:50  OFF CAMERA So what has that been like for you knowing Jeremy’s smoking crack?

00:05:55  LISA Well, I’ve never seen him do drugs before. You know he drinks a lot, smokes weed, but crack cocaine. I mean God have mercy.

00:06:15  OFF CAMERA What are you thinking about?

00:06:20  LISA Everyone’s going to know.

00:06:25  OFF CAMERA Know what?

00:06:30  LISA That I was getting high to stay in this hospital and get cleaned up.

00:06:35  OFF CAMERA You mean rather than go to rehab.

00:06:40  LISA Rehab, man they’re fucking dirty places and I’m sick and tired of dirty places.

00:06:45  OFF CAMERA No, no, no this rehab place is very clean. I’ve seen it. There are a lot of nice people there. People who feel like they get much better help than here in the hospital. In fact, I can call someone for you and let you talk with them.

00:06:55  LISA No, no, no, no, no, no, no, no, don’t do that.

00:07:00  OFF CAMERA You’re really fearful of going to rehab.

00:07:05  LISA Well if everyone finds out that I’ve been to rehab, I won’t get a job. I won’t be hired anyway.

00:07:10  OFF CAMERA Plus if people are fearful of the stigma and fearful of what people will think of them.

00:07:20  LISA Yeah, but he says that I’m not addicted. It’s just — you know something wrong with my personality.

00:07:25  OFF CAMERA Who says there’s something wrong with your personality?

00:07:30  LISA Jeremy.

00:07:30  OFF CAMERA When did he tell you that?

00:07:35  LISA Lots of times.

00:07:35  OFF CAMERA I thought you said you and Jeremy split up after you caught him cheating.

00:07:40  LISA I —

00:07:45  OFF CAMERA It’s okay. Take your time.

00:07:50  LISA Well yeah he moved back in.

00:07:50  OFF CAMERA Into your new home?

00:07:55  LISA Yeah. What changed that you two decided to get back together?

00:08:00  OFF CAMERA Well he said he was sorry and he begged me. He’s done it before so I took him back.

00:08:1  0LISA And how has that been being back with Jeremy?

00:08:15  OFF CAMERA Well I love Jeremy. I do and don’t want to go out and find another boyfriend. I mean we lost 80,000 dollars on that business. And he promised me that he would make it all back.

00:08:30  LISA So is that why you took him back? Has Jeremy continued smoking crack?

00:08:45  OFF CAMERA Yeah a little but he’s not addicted. He says that it calms him down. Me too.

00:09:05  LISA You too?

00:09:05  OFF CAMERA So do you smoke crack with Jeremy?

00:09:15  LISA Yeah we — he made me try it.

00:09:25  [sil.]

00:09:30  [ Crying ]

00:09:40  LISA And then he tried just once. We did it together. [Inaudible] I could.

00:09:55  [ Crying ]

00:10:00  LISA Hit me like a bullet. And it felt so good. I felt so good. And real fast.

00:10:20[sil.]

00:10:25  LISA Have you ever felt like you were dancing with butterflies?

00:10:30  OFF CAMERA Dancing with butterflies? No I have not.

00:10:40  [sil.]

00:10:45  LISA But he says it’s not addictive, Jeremy.

00:10:50  OFF CAMERA What do you think?

00:10:55  LISA Well I know I can’t get enough.

00:11:00  [ Crying ]

00:11:10  LISA And I know I don’t want to go back to feeling horrible again because when I don’t smoke it I get worse. And when I have it, I feel good. And then it’s gone. And then I know that I’m going to be needing another hit.

00:11:45  OFF CAMERA That sounds a lot like addiction.

00:11:55  LISA Yeah but I know I don’t want it to be.

00:12:00  OFF CAMERA It sounds like you are very scared of getting help and yet at the same very time, it sounds like you know you need that help.

00:12:15  LISA I know I don’t need help. I don’t need anything. Jeremy promised me that everything is going to be okay. And when you love someone like I do, you got to believe him. Right?

00:12:45  [sil.]

00:12:45 END TRANSCRIPT

Assignment Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Expert Answer and Explanation

Substance Abuse Disorder

Subjective:

CC: “I am scared and worried about going to a rehab facility.”

HPI: Lisa Pittman is a 29-years-old female of white origin. She came to West Palm Beach, FL, detox facility to get a piece of advice on whether to join a rehab institution. Lisa is scared of joining a rehab facility because of how society will treat her. She says that if she goes to rehab, she will not get a job. She is also scared that people will see her as an addict when she joins a rehab facility.

She says that Jeremy, her boyfriend influenced her to take crack cocaine. She spends a lot of money on cocaine. She says that she has to use cocaine regularly to feel good. She reports that if she does not use cocaine, she will feel worse and horrible. She continues to use cocaine even if she knows that she needs help. Her cocaine use has affected her daily activities. She does not eat properly and has poor sleeping habits.

Past Psychiatric History:

  • General Statement: No history of treatment for psychiatric conditions.
  • Caregivers (if applicable): No Caregivers
  • Hospitalizations: No hospitalization.
  • Medication trials: No prior history of medical trials.
  • Psychotherapy or Previous Psychiatric Diagnosis: The patient has never undergone psychiatric treatment and has no mental problems.

Substance Current Use and History: She says that she takes crack cocaine. He spends $100 daily to buy cocaine. She uses cannabis. She takes it about 1-2 times weekly. She drinks 2-3 bottles of alcohol once weekly.

Family Psychiatric/Substance Use History:  Her brother has a history of opioid abuse. Her father was jailed for drug possession. Her mother has a history of benzodiazepine abuse and anxiety.

Psychosocial History: She was born in Alabama, where her parents raised her. Her mother raised her after her father was jailed when she was 5-7 years old. She has a single sibling, a brother who has not visited them for ten years. She currently lives with her boyfriend in Florida. She has a daughter who lives with her friends.

She studied digital marketing in college. She likes to party with friends and get high. She was convicted for possessing drugs and is currently on probation. She is a digital marketer and creates commercial websites for businesses. Her father sexually assaulted her when she was 5-7 years old. She recently witnessed her boyfriend having sexual intercourse with another woman.

Medical History: Lisa has hepatitis C.

  • Current Medications: No medications
  • Allergies: She has amoxicillin allergies.
  • Reproductive Hx: She is sexually active. The menstrual cycle is regular. She uses an intrauterine device as her contraceptive method. There are no reproductive concerns.

ROS:

  • GENERAL: Positive for low appetite. No weakness, chills, fever, or fatigue.
  • HEENT: No abnormalities.
  • SKIN: No itching.
  • CARDIOVASCULAR: No chest pain, edema, leg cramps, dyspnea, or ankle swelling.
  • RESPIRATORY: No pain with breathing, cough, or shortness of breath.
  • GASTROINTESTINAL: No abdominal pain, constipation, vomiting, nausea, or diarrhea.
  • GENITOURINARY: No genital lesions, dysuria, odor, retention, hematuria, or inconsistency.
  • NEUROLOGICAL: No sensory-motor loss, dizziness, headaches, or focal weakness.
  • MUSCULOSKELETAL: No musculoskeletal abnormalities.
  • HEMATOLOGIC: No anemia
  • LYMPHATICS: No gland swelling or HIV.
  • ENDOCRINOLOGIC: No polydipsia.

Objective:

Physical exam:

 Vital Signs: BP 178/94, Wt. 140lbs, P 101, Ht. 5’6″, T 99.8

  • HEENT: Head: No scars or swelling. Eyes: No glasses, PERRL, sight intact, conjunctivae clear, sclera white. Ears: TMS appears normal. Hearing intact and canal clear. Nose: No mucosal edema. Mucosa pink and moist, nares are patent and discharge clear. Throat: No inflammation.
  • Skin: No rash.
  • Cardiovascular: Regular heartbeats and rates. No ankle edema. No murmurs. No gallops. Pulse normal.
  • Respiratory: Chest clear. Breathing rate normal. No problems with breathing. Lungs clear.
  • Neurological: Cranial nerves intact.
  • Musculoskeletal: Normal gait.

Diagnostic results:

  • Laboratory test results include albumin 3.0, GGT 59, ALT 168, bilirubin 2.5, and ALK 250. The patient tests positive for cocaine in her urine. Other lab results are normal.
  • CRAFFT Screener: This tool can help a psychiatrist can be used to identify the presence of substance abuse or make an addiction diagnosis (Bivin & Riaz, 2017(. The patient scores high.
  • Drug and Alcohol Problem Quick Screen (DAP Quick Screen): This tool can help nurses assess the patient with substance abuse’s relations with people around them (Bivin & Riaz, 2017). The patient scores high.

Assessment:

Mental Status Examination: Lisa is well-developed as looks her stated age. She does not appear ill. She is not well-groomed. She engaged in the interview. Her speech is clear but slow. She is alert and oriented. Her mood is liable, and her affect is consistent with the mood. She looks frustrated. She holds her bag when speaking. Thought content is grossly intact. Her concertation is good. She denies suicidal thoughts, hallucinations, delusions, or paranoid thoughts. Judgment is impaired, but insight intact.

Differential Diagnoses: 

  1. Cocaine Use Disorder (CUD)
  2. Substance Use Disorder (SUD)
  3. Alcohol Use Disorder (AUD)

Primary Diagnosis 

The primary disorder is cocaine use disorder. Zaparte et al. (2019) note that CUD causes irritability, anxiety, memory problems, and lack of concertation. Gómez Pérez et al. (2020) also note that patients with CUD have sleep problems and often crave the drug. Other symptoms of CUD include the feeling to use the drug daily, using the substance even if one knows it is not healthy, possessing the drug, spending a lot of money on the drug, inability to function without the drug, and taking the substance in excess to achieve the same effect (APA, 2013).

A person with CUD often feels the need to stop taking cocaine but cannot (Sadock et al., 2015). CUD has been included as the primary diagnosis because the patient meets all the DMS-5 criteria for diagnosing the disorder. She spends a lot on cocaine, was arrested for possessing the drug, feels the urge to use the drug daily, needs a lot of cocaine to feel good, and is afraid of withdrawing from cocaine addiction because she fears feeling worse without the drug. She also prefers to get high rather than eat and has sleep problems. CRAFFT Screener and DAP Quick Screen results confirm the diagnosis.

The second diagnosis for this case is SUD. McCabe et al. (2019) note that substance abuse causes tolerance, using the substance continuously when it is problematic, and the desire to withdraw and craving. The DSM-5 highlights that the symptoms of substance abuse include physical dependence, risky use, impaired control, and social issues as a result of using substances (APA, 2013).

SUD has been included because the patient uses cocaine, alcohol, and cannabis. However, it is a secondary disorder because she is only addicted to cocaine. AUD has been included because the patient drinks alcohol weekly. Mattick et al. (2018) note that AUD causes alcohol dependence. This disease is a secondary disorder because the patient does not depend on alcohol. She depends more on cocaine.

Reflections: 

I support the diagnosis because it is supported by evidence-based literature and the patient’s subjective and objective data. If I was assigned this case again, I would have conducted an anxiety screening. The patient reports fear, and thus I would like to know whether she has anxiety. I would also ask the patient about her work and whether she can work without using cocaine. I would ask the patient if she cannot stay without drinking alcohol. Her answer would help me further support my diagnosis.

Nurses should assess patients with the knowledge about ethical considerations they need to follow. This patient came to the clinic to seek advice on whether to join a rehab center. She has the autonomy to make decisions on whether to go to rehab or not. The nurse, in this case, should give advice and not force the patient. The nurse should also not market the rehab center; they should provide educative material and let the patient decide.

It is also unethical to judge the patient during the assessment. The nurse should be objective to give partial and evidence-based advice. Another vital ethical consideration is the therapeutic relationship. The nurse should maintain a professional relationship with the patient to improve the quality of care provided. If the nurse becomes close to the patient, their judgment will be compromised, leading to poor quality care.

References

American Psychiatric Association. (2013). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm16

Bivin, J. B., & Riaz, K. M. (2017). Assessment of substance abuse among teenagers: Review of instruments commonly used in healthcare and research. Asian Journal of Nursing Education and Research, 7(2), 248-254.

Gómez Pérez, L. J., Cardullo, S., Cellini, N., Sarlo, M., Monteanni, T., Bonci, A., … & Madeo, G. (2020). Sleep quality improves during treatment with repetitive transcranial magnetic stimulation (rTMS) in patients with cocaine use disorder: A retrospective observational study. BMC psychiatry, 20(1), 1-12. https://doi.org/10.1186/s12888-020-02568-2

Mattick, R. P., Clare, P. J., Aiken, A., Wadolowski, M., Hutchinson, D., Najman, J., … & Degenhardt, L. (2018). Association of parental supply of alcohol with adolescent drinking, alcohol-related harms, and alcohol use disorder symptoms: a prospective cohort study. The Lancet Public Health, 3(2), e64-e71. https://doi.org/10.1016/S2468-2667(17)30240-2

McCabe, S. E., Veliz, P. T., Boyd, C. J., Schepis, T. S., McCabe, V. V., & Schulenberg, J. E. (2019). A prospective study of nonmedical use of prescription opioids during adolescence and subsequent substance use disorder symptoms in early midlife. Drug and Alcohol Dependence, 194, 377–385. https://doi.org/10.1016/j.drugalcdep.2018.10.027

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Zaparte, A., Schuch, J. B., Viola, T. W., Baptista, T. A., Beidacki, A. S., do Prado, C. H., … & Grassi-Oliveira, R. (2019). Cocaine use disorder is associated with changes in Th1/Th2/Th17 cytokines and lymphocytes subsets. Frontiers in Immunology, 10, 2435. https://doi.org/10.3389/fimmu.2019.02435

Alternative Expert Answer and Explanation

Substance Abuse Disorder

Subjective:

CC: “You’re going to have to convince me – going to rehab.”

HPI LP is a 29-year-old white female patient who came to the clinic for an evaluation and possibly treatment. She notes her fear of going to rehab and does not want to believe that she is an addict because of what people may think of her. Instead, she believes she may be having a problem with her personality as she was told by her boyfriend. She notes to be using alcohol and cocaine, which has worsened since she saw her boyfriend cheating with a colleague. She also indicates that she always feels good after smoking cocaine and is miserable when she is not, making her always want some more.

Substance Current Use and History: The patient is currently using both alcohol and cocaine, which she indicates to have been using for some time after being introduced by her boyfriend. She drinks 2-3 bottles of alcoholic drinks once a week, smokes cannabis once or twice every week, and approximately uses $100 in cocaine daily. She has been previously convicted of being in possession of drugs and is currently under 2-year probation with randomized drug screenings. The patient also prefers to get high instead of eating.

Family Psychiatric/Substance Use History: The patient’s father is convicted of drug and sexual abuse charges, while her mother has a history of benzodiazepine use. Brother has a history of opioid use and has not gotten in touch with the family for the past 10 years.

Psychosocial History: the patient has a history of sexual abuse from when she was still a child committed by her father. She currently lives with her boyfriend, who has a history of substance abuse that has affected their ability to properly manage finances. The patient also has a daughter but lives with some friends. The patient also has a history of theft and drug convictions and is currently under probation. She also has a website development business which she runs with her boyfriend.

Medical History: The patient is positive for Hep C

  • Current Medications: Not under any medications
  • Allergies:
  • Reproductive Hx:No abnormalities reported

ROS:

  • GENERAL: Decreased appetite. No chills or fever, negative for fatigue or weakness.
  • HEENT: No abnormalities noted
  • SKIN: No itching, dryness, or rashes
  • CARDIOVASCULAR: Negative for any chest pain or discomfort.
  • RESPIRATORY: Negative for shortness of breath, breathing difficulties, or coughs.
  • GASTROINTESTINAL: Negative for abdominal pain, nausea, vomming, or diarrhea.
  • GENITOURINARY: Negative for GI symptoms
  • NEUROLOGICAL: Negative for headaches or other neurological issues
  • MUSCULOSKELETAL: No MS abnormalities.
  • HEMATOLOGIC: denies any hematologic issues.
  • LYMPHATICS: No lymphadenopathy.
  • ENDOCRINOLOGIC: Negative for polydipsia or polyuria.

Objective:

Physical exam: GENERAL:

Vital Signs: T- 99.8 P- 101 R 20 BP 178/94 Ht 5’6 Wt 140lbs

  • HEENT:
    • Head: Clear of any deformities, scars, or swelling.
    • Eyes: White scleral, conjunctiva clear, visual acuity 20/20.
    • Ears: Hearing intact, no discharge.
    • Nose: Mucosa moist and pink, nares are patent.
    • Throat: No inflammation or pain noted.
  • Skin: Skin appears moist with no rash or wounds.
  • Cardiovascular: Normal HR and BP. Negative for murmurs or bruits.
  • Respiratory: Lungs clear. No wheezing sound or pain in respiration.
  • Gastrointestinal: N/A
  • Neurological: Cranial nerves intact.
  • Musculoskeletal: No observable issues.

Diagnostic results:

Diagnostic results on admission indicate: abnormal for ALT 168, albumin 3.0, bilirubin 2.5, GGT 59; ALK 250. Her UDS also indicates positive for cocaine. Her BAL is 0, with THC showing negative for other drugs and alcohol. Other labs were within the normal range.

  • Drug Use Screening Inventory-Revised (DUSI-R): Positive for cocaine abuse

Assessment:

Mental Status Examination: The patient is a 29-years-old white female whose physical appearance resembles her stated age. She appears with unkempt hair, and she is not properly groomed. She is alert throughout the interview but nervous about the idea that she may be sent to rehabilitation. She does not exhibit or indicate any signs or symptoms of paranoia, delusion, or having suicidal tendencies.

Differential Diagnoses: 

  1. Cocaine Use Disorder
  2. Alcohol use disorder
  3. Cannabis use disorder

Primary Diagnosis 

Of all the listed substances noted by the patient, cocaine was the most used and one on which the patient was dependent the most. Cocaine use disorder is one of the sub-categories of substance-related use disorders listed in the DSM-V manual, listed with F14 ICD-10 code. Cocaine use disorder involves overdependence on cocaine, despite the negative behavioral, cognitive, and physiological implications of the behavior.

Substance use can be diagnosed by confirming the level of dependence on the substance and other symptoms such as the presence of anxiety, inability to make rational decisions, and engaging in destructive behavior such as, stealing, to list a few (APA, 2013).

Reflections: 

The case presents one of the common substance use disorders being the second leading cause of substance-use deaths in the US, second only to opioid use (Bentzley et al., 2021). Some of the risk factors associated with cocaine use disorder include a family history of substance use (In this case, the patient’s, father, mother, brother, and now partner). Another risk factor is past traumatic events.

According to Moustafa et al. (2021), early childhood, traumatic experiences may increase the risk of cocaine and other substance use disorder which occurs from efforts to self-medicate in trying to deal with the stress response. The same is also true for adults, where a stressful event such as a breakup with a loved one could trigger substance use.

All these factors are seen in the presented case. One of the ethical considerations, in this case, is respecting the patient’s autonomy respecting her decision on the mode of treatment. The patient should be informed about the underlying responsibilities that are affected by her behavior, including irresponsible financial decisions and her role as a mother, which will help her dedicate herself to the prescribed intervention.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (Vol 5). (2013). American psychiatric association.

Bentzley, B. S., Han, S. S., Neuner, S., Humphreys, K., Kampman, K. M., & Halpern, C. H. (2021). Comparison of treatments for cocaine use disorder among adults: A systematic review and meta-analysis. JAMA network open4(5), e218049-e218049.

Moustafa, A. A., Parkes, D., Fitzgerald, L., Underhill, D., Garami, J., Levy-Gigi, E., & Misiak, B. (2021). The relationship between childhood trauma, early-life stress, and alcohol and drug use, abuse, and addiction: An integrative review. Current Psychology40(2), 579-584.

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 ExcellentGoodFairPoor
Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.

In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS

18 (18%) – 20 (20%)

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

16 (16%) – 17 (17%)

The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

14 (14%) – 15 (15%)

The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.

0 (0%) – 13 (13%)

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.

In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
18 (18%) – 20 (20%)

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

16 (16%) – 17 (17%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

14 (14%) – 15 (15%)

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

0 (0%) – 13 (13%)

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.

In the Assessment section, provide:
• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
23 (23%) – 25 (25%)

The response thoroughly and accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

20 (20%) – 22 (22%)

The response accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.

18 (18%) – 19 (19%)

The response documents the results of the mental status exam with some vagueness or innacuracy.

Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy.

0 (0%) – 17 (17%)

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.

Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).9 (9%) – 10 (10%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

8 (8%) – 8 (8%)

Reflections demonstrate critical thinking.

7 (7%) – 7 (7%)

Reflections are somewhat general or do not demonstrate critical thinking.

0 (0%) – 6 (6%)

Reflections are incomplete, inaccurate, or missing.

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).14 (14%) – 15 (15%)

The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.

12 (12%) – 13 (13%)

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.

11 (11%) – 11 (11%)

Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.

0 (0%) – 10 (10%)

Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.

Written Expression and Formatting—Paragraph development and organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 (4%) – 4 (4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive.

3.5 (3.5%) – 3.5 (3.5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

Purpose, introduction, and conclusion of the assignment is vague or off topic.

0 (0%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.

No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and punctuation
5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors

4 (4%) – 4 (4%)

Contains a few (one or two) grammar, spelling, and punctuation errors

3 (3%) – 3 (3%)

Contains several (three or four) grammar, spelling, and punctuation errors

0 (0%) – 2 (2%)

Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding

Total Points: 100

 

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