Assessing And Diagnosing Patients With Substance Related And Addictive Disorders
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. Assessing And Diagnosing Patients With Substance Related And Addictive Disorders
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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? Assessing And Diagnosing Patients With Substance Related And Addictive Disorders
• 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.)Assessing And Diagnosing Patients With Substance Related And Addictive Disorders.
Subjective Data
Chief complaint: “I fear going to the rehab”
History of presenting complaint: Lisa Tremblay is a 33years old female who reports that she has fear of going to the rehabilitation center. She is also devastated because she feels that people think she is an addict. Additionally, she is devastated because of collapsing of her business after her boyfriend spent business money on buying crack and paying off his debts. She states that she has been taking a gallon of vodka daily, abusing opiates daily, smoking cannabis twice weekly, and using cocaine. She tries to leave indulgently in these substances but the boyfriend reassures her that she will be fine. She has given up on reviving her business, has lost interest in her friends, sleeps for at least 6hours a day, and prefers getting high to eating. She has a history of drug paraphernalia possession arrests. She denies hallucinations, delirium, confusion, and suicidal ideation Assessing And Diagnosing Patients With Substance Related And Addictive Disorders.
Psychiatric history: the patient suffered post-traumatic stress disorder after his father assaulted her at the age of six to nine years. She has had an estranged relationship with him since then. She denies depression, anxiety disorder, psychosis, and bipolar disorder.
Medication trial: none
Current medication: none
Psychotherapy and previous psychiatric diagnosis: the patient have had a history of sexual assault from his father. There is no record of psychiatric treatment and psychotherapy sessions.
Substance abuse: the patient takes half a gallon of vodka daily, has been abusing opiates daily, smokes cannabis twice weekly, and cracks cocaine daily. Moreover, she has a history of drug paraphernalia possession arrest and prefers getting high to eating.
Family history: the patient is the second born in a family of two. Her parents are separated because his father is in jail due to sexual abuse of her and other drug charges. His mother is alive, has agoraphobia, and abuses benzodiazepines. His elder brother lost contact with his family ten years ago and has a history of opioid abuse. She denies a family history of cancer, lifestyle diseases, and asthma.
Social history: the patient is single and has one daughter who lives with her friend. She is currently living alone after breaking up with her boyfriend. She has been in a strained relationship with her boyfriend because they break up often and reports that the man has been cheating on her with other women. The patient states she had a good business until it collapsed because his boyfriend mismanaged the business money. She enjoys the company of her friends when taking vodka. She has a history of drug possessions and is currently on drug screening probation Assessing And Diagnosing Patients With Substance Related And Addictive Disorders.
Medical history: she has hepatitis C
Allergies: she develops a rash a peeling skin due to itchiness after taking azithromycin. She relieves the allergies by taking over-the-counter antihistamines.
Review of systems
General: the patient is clinically febrile. She denies fatigue, weight loss, malaise, night sweats, and weight gain.
HEENT: The patient denies headache, eye ache, blurring of vision, runny nose, nasal stuffiness, ear ache, loss of hearing, and throat pain.
Cardiovascular system: she denies syncope, dizziness, dyspnea, palpitation, orthopnea, chest pain, and paroxysmal nocturnal dyspnea.
Respiratory system: the patient denies chest pain, coughing, runny nose, wheezing, sputum production, and difficulties in breathing.
Gastrointestinal system: the patient has reduced appetite. She denies abdominal pain, diarrhea, vomiting, heartburn, reflux, nausea, and constipation.
Genital-urinary system: the patient denies dysuria, polyuria, hematuria, oliguria, lower abdominal pain, vaginal discharge, dyspareunia, sexually transmitted infections, and urine incontinence.
Musculoskeletal system: the patient denies joint pain, stiffness, fracture, and muscle spasms.
Neurological system: the patient denies facial droop, paralysis, muscle weakness, paresthesia, and numbness.
Skin: the patient denies skin itchiness, acne, and peeling.
Endocrine: she denies heat and cold intolerance, striae, irritability, and night sweats.
Hematologic system: he denies bleeding tendencies, frequent infections, and anemia Assessing And Diagnosing Patients With Substance Related And Addictive Disorders.
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Objective Data
General: the patient is calm and oriented. she has a ting of jaundice and pallor. She has no cyanosis, dehydration, or lymphadenopathy.
Vitals: the temperature at 100F, blood pressure at 180/110mmHg, the pulse rate at 108, height of 5’6, and weight of 146Ibs.
Respiratory system: she has symmetrical chest movements. There is a resonant percussion note with vesicular breath sounds. There are no crackles and wheezing.
Cardiovascular system: the heart sounds are present in S1 S2 without murmurs. The peripheral pulses are present at a regular rate and rhythm. There are no bruits.
Abdominal examination: the abdomen is round and soft. The bowel sounds are present. There are no fluids thrills and shifting dullness.
Diagnostic investigations: the laboratory findings are abnormal for ALT 168, AST 200, ALK 250, bilirubin 2.5, and albumin 3.0. Her GGT is 59; UDS positive for opiates, THC Positive for alcohol or other drugs. BAL .308; other labs within normal ranges.
Assessment
Mental state examination
The patient is neat and appropriately dressed for the occasion and weather. She is oriented to time, place, and person. She is uncooperative initially because she didn’t want to start the conversation. She seems restless during the interview, fidgets, and threatens to leave the room. She does not maintain eye contact and her speech gets out of context. Her speech tone, volume, and speed are ranging from soft to normal volume such that it is straining to listen. She uses rude and abusive words when describing her boyfriend thus showing that she is bitter with her. Her mood is sad with a flat affect because she cries during the interview. Her judgment and insight are poor because she thinks that she is not addicted and does not need rehabilitation. However, she has no hallucinations, delirium, and suicidal ideation Assessing And Diagnosing Patients With Substance Related And Addictive Disorders.
Differential diagnoses
- Substance use disorder-F19.10
- Substance induced anxiety disorder-F19.280
- Drug addiction F19.20
Primary diagnosis: substance use disorder is a mental health illness associated with the use of illicit and illegal substances like alcohol, prescription drugs like opioids, stimulants, cannabis, and tobacco. Patients with substance use disorder have a persistent urge to stop using the substance, continue using the substance despite its implications, use the substance in large amounts, and continue to use the substance despite causing interpersonal problems (Bruijnen, et al, 2019). The cause of substance abuse is a genetic predisposition, peer influence, and neurobiological causes. The patient takes alcohol daily in large amounts, cracks cocaine with her boyfriend, smokes cannabis twice weekly, and takes opiates daily. Substance use disorder is the appropriate diagnosis because the patient spends a lot of money and opiates, takes in large amounts, is unable to stop, and continues taking despite having conflicts with her boyfriend and contracting hepatitis C. According to Pietschmann, T., & Brown, R. J. (2019)Assessing And Diagnosing Patients With Substance Related And Addictive Disorders, Hepatitis C is a viral infection caused by direct contact to infected blood. It is common in people who share drug injections needles and unprotected anal sexual intercourse. She has a fever, mild palpitations, a tinge of jaundice, and mild abdominal pain.
Substance-induced anxiety disorder is a generalized anxiety disorder caused by taking alcohol, smoking cannabis, and using other prescription drugs. The majority of patients with substance use anxiety tend to indulge in drugs and other substances to help them relax, boost their confidence, and lower their inhibitions (Turner, et al, 2018) Substances that cause anxiety are alcohol, cannabis, cocaine, and opioids. Causes of substance-induced anxiety are the constant need for validation, past traumatic events, and family history. The patient presents with excessive worry that she might be addicted. She uses these substances to feel high, relaxed, and well such that she opts getting high on eating. Additionally, substance use makes her feel more connected to her boyfriend during the low moments of their relationship. the patient has a positive family history of agoraphobia from her mother who also abuses benzodiazepines. However, this is not the actual diagnosis because the patient does not exhibit symptoms of anxiety like chest pain, palpitations, insomnia, and inability to concentrate.
Drug addiction or substance abuse is the constant need of indulging in drugs or other dangerous substances to gain stimulation. The presenting symptoms are withdrawal symptoms, difficulties in quitting or cutting down, withdrawal from social recreations, and continuous use despite the physical and psychological issues. The drugs that cause addictions are alcohol, marijuana, cocaine, opiates, hallucinogens, and inhalants (Wise, et al, 2021)Assessing And Diagnosing Patients With Substance Related And Addictive Disorders. The patient is abusing alcohol, opiates, cannabis, and marijuana. She has tried to quit the use of these substances unsuccessfully. However, she does not explain the need to increase the amount she has been taking and the presence of withdrawal symptoms. Additionally, she has maintained her social interactions with friends. She seems dedicated to her business because she sounds bitter about the collapse of the business. Therefore, this is not the actual diagnosis.
Reflection
The interview session was informative. I learned how to initiate a conversation with a patient with a substance-related disorder. I learned that the cause of substance use disorder is over-indulging in these drugs. Examples of commonly abused drugs are opiates, hallucinogens, cannabis, alcohol, cocaine, and stimulants. The causes can be genetic predisposition, cognitive factors, social-cultural, and behavioral factors. Genetic predisposition causes a higher hereditary link to substance abuse. Neurobiological factors are in the brain reward system that influences the user to have pleasurable moments (Horseman, C., & Meyer, A. 2019). The cognitive factors are the desire to have a particular outcome of the drug for example feeling calm. Behavioral factors influencing substance use are either reinforcement or punishment, that is, a person abuses the drug more often to achieve positive reinforcement like relaxation (Cardoso, J. B. 2018). Social-cultural factors are peer influence and curiosity about the outcome. This patient was influenced by her friends to indulge in these substances, has a family history of drug use, and has a strong urge to use the drugs for relaxation of feeling high. In the future, I will use open-ended questions on the patient to enable them to give more information. Few close-ended questions will help in getting direct answers. I also welcome the patient and assure them of privacy and confidentiality.
References
Bruijnen, C. J., Dijkstra, B. A., Walvoort, S. J., Markus, W., VanDerNagel, J. E., Kessels, R. P., & De Jong, C. A. (2019). Prevalence of cognitive impairment in patients with substance use disorder. Drug and Alcohol Review, 38(4), 435-442. https://doi.org/10.1111/dar.12922
Cardoso, J. B. (2018). Running to stand still: Trauma symptoms, coping strategies, and substance use behaviors in unaccompanied migrant youth. Children and Youth Services Review, 92, 143-152. https://doi.org/10.1016/j.childyouth.2018.04.018
Horseman, C., & Meyer, A. (2019). Neurobiology of addiction. Clinical obstetrics and gynecology, 62(1), 118-127. https://doi.org/10.1097/GRF.0000000000000416
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Pietschmann, T., & Brown, R. J. (2019). Hepatitis C virus. Trends in microbiology, 27(4), 379-380. https://doi.org/10.1016/j.tim.2019.01.001
Turner, S., Mota, N., Bolton, J., & Sareen, J. (2018). Self‐medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. Depression and anxiety, 35(9), 851-860. https://doi.org/10.1002/da.22771
Wise, R.A., Jordan, C.J. Dopamine, behavior, and addiction. J Biomed Sci 28, 83 (2021). https://doi.org/10.1186/s12929-021-00779-7 Assessing And Diagnosing Patients With Substance Related And Addictive Disorders