NRNP 6635 WEEK 8 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
Subjective:
CC (chief complaint): “Persuade me to go to rehab.”
HPI: The video case depicts Lisa Tremblay, a 33-year-old woman currently undergoing treatment in a detox facility. She wants the clinician to persuade her to go to rehab. She is scared that people will think she is an addict if she goes to rehab. Lisa is worried about her business that she opened nine months ago, which she says has collapsed. She blames her boyfriend, Jeremy, for the business collapse because he was taking money from the business account. Jeremy used the business money to pay cocaine debts, leading to the business losing 80,000. Jeremy introduced Lisa to cocaine and convinced their that it would not cause addiction but would lead to addiction. Lisa feels on the edge when she has not smoked cocaine. When she uses cocaine, she feels good and is tempted to smoke more when the high feeling starts to fade. Lisa believes she needs no help since her boyfriend assured her she would be okay. She believes this because she loves her boyfriend.
Past Psychiatric History:
- General Statement: No significant psychiatric history.
- Caregivers (if applicable): None.
- Hospitalizations: None
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: None
Substance Current Use and History:
History of opiate use- Take $100 worth of opiates daily.
Uses cannabis 1–2 times weekly.
Alcohol use- Takes 1/2 gallon of vodka daily. She drinks with her friends and reports being in control of how much she drinks.
Family Psychiatric/Substance Use History: The mother has a history of agoraphobia and benzodiazepine abuse. The father was imprisoned with charges of drug abuse. The older brother has a history of opioid use.
Psychosocial History:
Lisa lives with her boyfriend, who has a strained relationship after he cheated on her. She has a daughter with her ex-boyfriend, who lives with her friends. The client and her boyfriend had a web design business, which crumpled after the boyfriend withdrew business money to pay debts. Lisa has a legal history of being arrested with charges of drug possession. She has a history of sexual abuse at 6-9 years by her estranged father. The father was imprisoned for sexual abuse and drug charges. The patient’s mother lives in Maine. She has an older brother whom she has not heard from for ten years. She sleeps 5-6 hrs/day. She prefers using drugs to eating.
Medical History: No medical illnesses.
- Current Medications: None
- Allergies: Allergic to Azithromycin.
- Reproductive Hx: None
ROS:
- GENERAL: Negative for fever, chills, weight changes, or malaise.
- HEENT: Negative for eye pain, ear pain, discharge, rhinorrhea, or sore throat.
- SKIN: Negative for rashes, lesions, or discoloration.
- CARDIOVASCULAR: Negative for dyspnea, edema, chest pain, or palpitations.
- RESPIRATORY: Negative for wheezing, cough, SOB, or sputum.
- GASTROINTESTINAL: Reports reduced appetite. Negative for abdominal pain or bowel changes.
- GENITOURINARY: Negative for dysuria or abnormal PV discharge.
- NEUROLOGICAL: Negative for dizziness, paralysis, or tingling sensations.
- MUSCULOSKELETAL: Negative for muscle or joint pain
- HEMATOLOGIC: Negative for bruising or bleeding.
- LYMPHATICS: Negative for lymph node swelling.
- ENDOCRINOLOGIC: Negative for excessive sweating, increased hunger, acute thirst, or polyuria.
Objective:
Physical exam:
Vital signs: BP-180/110; T- 100.0; P- 108; R-20; Ht- 5’6; Wt-146lbs
Diagnostic results:
- ALT-168
- AST-200
- ALK-250
- Bilirubin-2.5
- Albumin-3.0;
- GGT-59
- Urine drug test positive for opiates, THC, and alcohol
- BAL-308
Assessment:
Mental Status Examination:
Appearance: Neat and appropriately dressed for the weather and function. She seems nervous, constantly fidgets, and frequently looks out through the window
Mood: Anxious
Affect: Normal
Thought process: Coherent and goal-oriented
Thought content: No hallucinations, delusions, obsessions, or suicidal/homicidal ideations
Cognition: Oriented to person, place, and time.
Memory: Long-term and short-term are intact.
Judgment: Good
Abstract thought: Good
Insight: Present
Differential Diagnoses:
Substance Use Disorder (SUD): SUD presents with a maladaptive pattern of substance use, with one or more symptoms occurring within a 12-month period. The symptoms are Continued use of the substance even when aware of adverse consequences, Recurrent use despite physically hazardous situations, Failure to fulfill or role obligations, and Legal problems (APA, 2022; Pasha et al., 2020). Lisa uses cannabis and cocaine and usually smokes cocaine even when she does not want to. She reports feeling on the edge when she does not smoke. She is aware of the effects that cocaine has had on her business and relationship but continues to use it. Besides, she spends much money on purchasing cocaine daily and has been arrested for possession of drugs.
Alcohol Use Disorder (AUD): The clinical manifestations of AUD include Excessive and inappropriate drinking; Physical dependence with tolerance and withdrawal symptoms; Psychological dependence, with inability to control drinking; Inability to abstain; Tolerance; and Withdrawal symptoms (APA, 2022; Kranzler, 2023). This differential diagnosis is based on the patient’s history of excessive alcohol consumption, taking 1/2 gallon of vodka daily.
Generalized Anxiety Disorder (GAD): The clinical features of GAD include excessive and unwarranted anxiety or worry about life events that are usually difficult to control (DeGeorge et al., 2022). This is accompanied by symptoms like Restlessness, concentration difficulties, easy fatigue, irritability, sleeping difficulties, and muscle tension. Lisa expresses worry about going to rehab and her collapsing business, which makes GAD a differential. However, she does not exhibit other symptoms to make GAD the primary diagnosis.
Reflections: If I were to assess this patient again, I would assess the clinical course of substance use dependence. This includes when was the first use, the first intoxication, the first problem with cocaine/cannabis use, and the onset of dependence (Volkow & Blanco, 2023). Legal/ethical considerations for this patient related to confidentiality. Owing to the sensitivity of the patient’s drug use history, the clinician should assure the patient that the information will be kept confidential and only shared with her consent. The fear that the information may be used in legal cases may make the client omit important information that can aid in diagnosis and treatment. Health promotion and disease prevention should include educating the patient on the benefits of rehab and how it will help her address her cocaine dependency and excessive alcohol use (Gupta et al., 2023). Education on rehab can help reduce the stigma associated with it and help the patient get the maximum benefits from treatment.
References
American Psychiatric Association. (2022). Substance-related and addictive disorders. In Diagnostic and statistical manual of mental disorders
DeGeorge, K. C., Grover, M., & Streeter, G. S. (2022). Generalized Anxiety Disorder and Panic Disorder in Adults. American Family Physician, 106(2), 157–164.
Gupta, R., Wright, N. F., & Holtgrave, D. R. (2023). A 2023 Agenda for Substance Use Prevention and Treatment in the US. JAMA, 329(9), 707–708. https://doi.org/10.1001/jama.2023.1090
Kranzler, H. R. (2023). Overview of Alcohol Use Disorder. The American Journal of Psychiatry, 180(8), 565–572. https://doi.org/10.1176/appi.ajp.20230488
Pasha, A. K., Chowdhury, A., Sadiq, S., Fairbanks, J., & Sinha, S. (2020). Substance use disorders: diagnosis and management for hospitalists. Journal of Community Hospital Internal Medicine Perspectives, 10(2), 117–126. https://doi.org/10.1080/20009666.2020.1742495
Volkow, N. D., & Blanco, C. (2023). Substance use disorders: a comprehensive update of classification, epidemiology, neurobiology, clinical aspects, treatment and prevention. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 22(2), 203–229. https://doi.org/10.1002/wps.21073
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Assessing and Diagnosing Patients With Substance-Related 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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
Learning Resources
Required Readings
- American Psychiatric Association. (2022). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x16_Substance_Related_Disorders
- Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
- Chapter 4, “Substance Use and Addictive Disorders”
- Chapter 2 only section 2.17, “Adolescent Substance Abuse”
- Chapter 27 “Ethics and Professionalism”
- Chapter 28 “Forensic and Legal Issues”
- Document: Comprehensive Psychiatric Evaluation TemplateDownload Comprehensive Psychiatric Evaluation Template
- Document: Comprehensive Psychiatric Evaluation ExemplarDownload Comprehensive Psychiatric Evaluation Exemplar
Required Media
- Classroom Productions. (Producer). (2016). Addictive disordersLinks to an external site. [Video]. Walden University.
- Complex Care Consulting. (2018, April 4). Addiction neuroscience 101Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=bwZcPwlRRcc
Video Case Selections for Assignment
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.).
submission information
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- To submit your completed assignment, save your Assignment as WK8Assgn_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
NRNP_6635_Week8_Assignment_Rubric
Criteria | Ratings | Pts | ||||
---|---|---|---|---|---|---|
This criterion is linked to a Learning OutcomeCreate 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 |
|
20 pts | ||||
This criterion is linked to a Learning OutcomeIn 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. |
|
20 pts | ||||
This criterion is linked to a Learning OutcomeIn 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-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. |
|
25 pts | ||||
This criterion is linked to a Learning OutcomeReflect 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!), social determinates of health, 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.). |
|
10 pts | ||||
This criterion is linked to a Learning OutcomeProvide 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). |
|
15 pts | ||||
This criterion is linked to a Learning OutcomeWritten 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 pts | ||||
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation |
|
5 pts | ||||
Total Points: 100 |