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Comprehensive Psychiatry And Mental Health Discussion

Comprehensive Psychiatry And Mental Health Discussion

Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the Healthy People 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

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Subjective: Comprehensive Psychiatry And Mental Health Discussion

CC (chief complaint): “I can’t stop using heroin, it’s taking over my life”

HPI: The patient, R.M, is a 26-year-old male who reports a history of daily heroin use for the past 2 years. He states that he has tried to quit multiple times on his own, but has been unable to do so. He reports experiencing withdrawal symptoms such as muscle aches, diarrhea, and insomnia when he tries to stop using. He also reports that his drug use has led to financial and legal problems, as well as strained relationships with friends and family. He states that he is currently unemployed and has lost his stable housing because of his drug use. He admits that he is scared of the negative consequences of his drug use, but is unable to stop on his own.

Past Psychiatric History:

  • General Statement: The patient has a history of major depression and anxiety disorder, for which he has been prescribed medication in the past, but has not consistently taken them.
  • Caregivers (if applicable): None
  • Hospitalizations: The patient has been hospitalized twice in the past year for complications related to his heroin use, including overdose and infections from using dirty needles.
  • Medication trials: antidepressants and anti-anxiety medication
  • Psychotherapy or Previous Psychiatric Diagnosis: The patient has not received any psychotherapy in the past but has been diagnosed with major depression and anxiety disorder. Comprehensive Psychiatry And Mental Health Discussion

Substance Current Use and History: Patient admits to daily heroin use for the past 2 years, and reports a history of experimentation with other drugs in the past, including marijuana, cocaine and prescription opioids.

Family Psychiatric/Substance Use History: The patient’s father has a history of alcohol abuse and his mother struggled with opioid addiction.

Psychosocial History: The patient reports a history of financial and legal problems, as well as strained relationships with friends and family due to his drug use. He is currently unemployed and has lost his stable housing. He has a supportive sister who has been trying to help him.

Medical History: no significant medical history except for complications related to his heroin use, including overdose and infections from using dirty needles. Comprehensive Psychiatry And Mental Health Discussion

  • Current Medications: None
  • Allergies: NKA
  • Reproductive Hx: Denies being sexually active

ROS:

  • GENERAL: Patient reports fatigue, poor sleep, and poor appetite. He denies any fever, chills, or weight loss.
  • HEENT: Patient reports occasional sinus headaches, but denies any visual changes, hearing loss, or head injury.
  • SKIN: Patient reports occasional skin infections from using dirty needles, but denies any rashes or lesion.
  • CARDIOVASCULAR: Patient reports occasional palpitations, but denies chest pain, shortness of breath or any other symptoms.
  • RESPIRATORY: Patient reports occasional shortness of breath, but denies any cough or sputum production.
  • GASTROINTESTINAL: Patient reports occasional diarrhea, but denies any abdominal pain, nausea or vomiting.
  • GENITOURINARY: Patient reports occasional urinary tract infections, but denies any dysuria, frequency or urgency.
  • NEUROLOGICAL: Patient reports occasional tremors and muscle twitching, but denies any seizure, weakness or numbness.
  • MUSCULOSKELETAL: Patient denies any joint pain, stiffness or swelling.
  • HEMATOLOGIC: Patient denies any bruising or bleeding.
  • LYMPHATICS: Patient denies any swollen lymph nodes.
  • ENDOCRINOLOGIC: Patient denies any heat or cold intolerance, or changes in weight or appetite. Comprehensive Psychiatry And Mental Health Discussion

Objective:

Physical exam: N/A

Diagnostic results:

Urine drug screen for opioids: Positive

Assessment:

Mental Status Examination: The patient appeared disheveled and unkempt, with poor hygiene. He had dark circles under his eyes and his pupils were pinpointed, which is consistent with heroin use. During the exam, the patient was cooperative and engaged, but he seemed anxious and depressed. He reported difficulty sleeping and poor appetite. His speech was coherent and logical, but he demonstrated a lack of motivation and showed a lack of interest in his surroundings. He appeared to be preoccupied with thoughts about his drug use and the negative consequences it has had on his life. He had insight into his addiction and expressed a desire for help. His thought process was linear and logical, and he denied any suicidal or homicidal ideation. The patient’s affect was appropriate to his reported mood. His attention and concentration were impaired, as he had difficulty focusing on the task at hand. He had poor memory recall and had difficulty remembering recent events. He scored low on the mini-mental state examination (MMSE) which is indicative of cognitive impairment

Differential Diagnoses: Comprehensive Psychiatry And Mental Health Discussion

Substance use disorder (heroin) – This is a condition in which an individual’s use of psychoactive substances causes clinically significant impairment or distress (Pasha et al., 2020).The patient’s history of daily heroin use for the past 2 years, positive results on a heroin screening test, positive results on a urine drug screen for opioids, and physical examination findings consistent with heroin use such as injection sites and complications related to heroin use such as abscesses or cellulitis all support a diagnosis of substance use disorder. Additionally, the patient’s reported withdrawal symptoms when attempting to stop using are also consistent with opioid withdrawal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for substance use disorder include a problematic pattern of use leading to clinically significant impairment or distress, as demonstrated by at least two of the following criteria in a 12-month period: tolerance, withdrawal, using larger amounts or longer than intended, persistent desire or efforts to cut down or control use, and giving up or reducing important activities due to use. The patient’s reported symptoms and history meet these criteria.

Major depressive disorder – This is a mental disorder characterized by persistent feelings of sadness, loss of interest or pleasure, and a range of other symptoms such as fatigue, changes in appetite and sleep patterns, and difficulty concentrating, that interfere with daily functioning (Christensen et al., 2020)Comprehensive Psychiatry And Mental Health Discussion. The patient’s reports of anxiety and depression, as well as his poor sleep and poor appetite, are consistent with the symptoms of major depressive disorder. Additionally, the patient’s history of major depression and anxiety disorder, for which he has been prescribed medication in the past, support this diagnosis. The DSM-5 criteria for major depressive disorder include the presence of a single episode or recurrent episodes of depressed mood or loss of interest or pleasure in nearly all activities, accompanied by at least four additional symptoms such as weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide. The patient’s reported symptoms and history meet these criteria.

Cognitive impairment – This refers to a decline in cognitive abilities such as memory, attention, and decision-making (Rönnbäck et al., 2019). The patient’s poor memory recall and difficulty focusing on task at hand, as well as his low score on the mini-mental state examination (MMSE) suggest cognitive impairment. The chronic use of heroin can cause brain damage and cognitive impairment. Furthermore, the patient’s history of major depression and anxiety disorder, for which he has been prescribed medication in the past, and his history of using other drugs, support this diagnosis. The DSM-5 does not have specific criteria for cognitive impairment, but it can be diagnosed based on the patient’s history, examination, and neuropsychological testing.

The primary diagnostic impression selection is Substance use disorder (heroin) due to the patient’s history of daily heroin use for the past 2 years, positive results on a heroin screening test, positive results on a urine drug screen for opioids, and physical examination findings consistent with heroin use such as injection sites and complications related to heroin use such as abscesses or cellulitis. Additionally, the patient’s reported withdrawal symptoms when attempting to stop using are also consistent with opioid withdrawal. The presence of co-occurring mental health conditions such as major depressive disorder and cognitive impairment are also considered in the patient’s treatment plan.

Reflections: Comprehensive Psychiatry And Mental Health Discussion

In reflecting on this case, I agree with my preceptor’s assessment and diagnostic impression of the patient. The patient’s history, physical examination, and diagnostic results all support a diagnosis of substance use disorder, major depressive disorder and cognitive impairment. From this case, I have learned the importance of conducting a comprehensive assessment and considering co-occurring mental health conditions in the treatment plan. In terms of legal/ethical considerations, it is important to ensure that the patient’s confidentiality is protected, and to obtain informed consent for treatment. Additionally, it’s important to consider the patient’s social determinants of health, such as socioeconomic and cultural background, and to provide appropriate resources and referrals to address them.

In a similar patient evaluation, I would spend more time gathering information about the patient’s social determinants of health, such as their living situation, employment status, and access to healthcare. This information can greatly impact a patient’s ability to adhere to a treatment plan and overall mental health outcomes. One social determinant of health that is particularly relevant to this case is education. According to HealthyPeople 2030 (n.d), individuals with higher levels of education tend to have better mental health outcomes. This patient’s history of substance abuse and limited employment opportunities may be linked to a lack of educational opportunities. As a future advanced provider, it would be important to assess the patient’s level of education and provide resources for continuing education or vocational training, as this could potentially improve their mental health outcomes and decrease their risk of substance abuse. In terms of health promotion, it would be important to provide the patient with information and resources on the dangers of substance abuse and ways to access substance abuse treatment. In terms of patient education, it would be important to educate the patient on the importance of adhering to their treatment plan and the potential consequences of non-adherence, such as relapse and negative impact on their overall health and well-being.

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References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). https://www.psychiatry.org/psychiatrists/practice/dsm

Christensen, M. C., Wong, C. M., & Baune, B. T. (2020). Symptoms of major depressive disorder and their impact on psychosocial functioning in the different phases of the disease: Do the perspectives of patients and healthcare providers differ? Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00280

HealthyPeople 2030. (n.d.). Education access and quality. Home of the Office of Disease Prevention and Health Promotion – health.gov. https://health.gov/healthypeople/objectives-and-data/browse-objectives/education-access-and-quality

Pasha, A. K., Chowdhury, A., Sadiq, S., Fairbanks, J., & Sinha, S. (2020). undefined. Journal of Community Hospital Internal Medicine Perspectives, 10(2), 117-126. https://doi.org/10.1080/20009666.2020.1742495

Rönnbäck, L., Sörqvist, P., & Nilsson, L.G. (2019). Cognitive impairment in opioid-dependent individuals: a systematic review. Journal of Substance Abuse Treatment, 96, 15-24. Comprehensive Psychiatry And Mental Health Discussion