NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template

Week (enter week #): Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint): ‘I am afraid to go to the rehab.’

HPI: Lisa Pittman is a 29-year-old female that has come to the unit for treatment for Hep C+ and needs to get clean first. She is thinking of going for long-term rehab but is fearful of what people will say and the perception that they are dirty. Lisa has been smoking crack cocaine, approximately $1000 daily, cannabis 1-2 times weekly, and 2-3 alcoholic drinks weekly. She also has a history of theft convictions and drug possessions and is on a 2-year probation with randomized drug screens. Her laboratory values have demonstrated abnormal results in ALT, AST, bilirubin, albumin, GGT, and positive for cocaine. She has a history of sexual abuse as a child, with perpetrator being her father who was imprisoned for the offence and drug charges. Lisa is currently in a relationship with Jeremy, who also abuses drugs and alcohol. She has a daughter who lives with her friends.

Past Psychiatric History:

• General Statement: I am afraid of going to the rehab
• Caregivers (if applicable): none
• Hospitalizations: Lisa denied any history of hospitalizations
• Medication trials: Lisa denied any history of medication trials
• Psychotherapy or Previous Psychiatric Diagnosis: Lisa denied any history of psychotherapy or previous psychiatric diagnosis

Substance Current Use and History: Lisa currently abuses cannabis 1-2 times weekly, smokes crack cocaine, and drinks 2-3 alcoholic drinks weekly

Family Psychiatric/Substance Use History: There is history of substance abuse in Lisa’s family. Her father was imprisoned for sexually abusing her and drug offenses. Her mother has a history of benzodiazepine use. Her older brother has history of opioid abuse. Her mother has a history of anxiety.

Psychosocial History: Lisa is not married. She is in a relationship with Jeremy. She current works and struggles to remain clean so that people do not talk about her. She has a daughter who stays with her friends.

Medical History: Lisa denied any history of hospital admission, surgeries, or blood transfusion.

• Current Medications: Lisa is not currently using any medications
• Allergies: She is allergic to Amoxicillin. She denied other forms of allergies.
• Reproductive Hx:Her menarche was when she was 15 years. Her last menstrual period was one week ago. She is currently not using any contraceptive method. She denies any menstrual problems. She is sexually active. She does not use any protection when engaging in sexual intercourse. She has one child. She denied any history of pregnancy loss. She denied history of sexually transmitted infections. She denied dysuria, urgency, and frequency. She was sexually abused when she was aged 5-7 by her father.

ROS:

• GENERAL: Lisa appears poorly groomed for the occasion. She is slightly underweight for her age. She does not demonstrate restlesses, agitation, and denies fever
• HEENT: Eyes: Lisa denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: She also denies hearing loss, sneezing, congestion, runny nose, or sore throat.
• SKIN: Lisa denies rash or itching. There are evident needle prick marks on the arms.
• CARDIOVASCULAR: Lisa denies chest pain, chest pressure, or chest discomfort. She also denies palpitations or edema.
• RESPIRATORY: Lisa denies shortness of breath, cough, or sputum.
• GASTROINTESTINAL: She denies anorexia, nausea, vomiting, or diarrhea. She also denies abdominal pain or blood. She reports decline in appetite. She prefers getting higher to eating.
• GENITOURINARY: Lisa denies burning on urination, urgency, hesitancy, odor, odd color
• NEUROLOGICAL: Lisa denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. She also denies change in bowel or bladder control.
• MUSCULOSKELETAL: Lisa denies muscle, back pain, joint pain, or stiffness.
• HEMATOLOGIC: Lisa denies anemia, bleeding, or bruising.
• LYMPHATICS: She denies enlarged nodes. No history of splenectomy.
• ENDOCRINOLOGIC: She denies reports of sweating, cold, or heat intolerance. She also denies polyuria or polydipsia.

Objective:

Physical exam: if applicable

Diagnostic results: laboratory investigations were ordered. The labs were abnormal for ALT 168, AST 200, ALK 250, bilirubin 2.5, albumin 3.0, GGT 59, and UDS positive for cocaine. The labs were negative for alcohol or other drugs. BAL o; other labs within normal range.

Assessment:

Mental Status Examination: Lisa is poorly groomed for the occasion. She is oriented to self, time, place, and events. She maintains normal eye contact during the assessment. Her speech is normal in terms of tone, volume, and rate. She does not demonstrate tics or tremors during the assessment. She responds appropriately to questions. She denies illusion, delusion, and hallucinations. Her thought content is future oriented. She denies suicidal thoughts, attempts, or plans. Her mood is flat with constricted affect.

Differential Diagnoses:

Lisa’s primary diagnosis is substance use disorder. According to DSM5, substance use disorders are mental health problems that arise from the abuse of drugs that include alcohol, caffeine, cannabis, hallucinogens, opioids, hypnotics, stimulants, tobacco, and sedatives. Prolonged use of these drugs result in substance use disorders where patients continue using them despite experiencing problems associated with them (Jones & McCance-Katz, 2019). DMS5 has developed criteria that practitioners utilize in diagnosing patients with substance use disorders. One of them is an individual taking a substance in larger amounts and for longer periods than it was intended. It also includes individuals having the intention to stop or cut down using the substance but he/she is unable. The additional symptoms include spending a lot of time in acquiring, using, or recovering from the substance and having immense cravings and urges to use it. Substance use also affects the normal functioning of its users. In addition, the users continue abusing them even it they cause problems in their lives or relationships (Arterberry et al., 2020). Substance use disorder patients also require more of the drug to achieve the effect they want, develop withdrawal symptoms when they abstain, and continue using the substance even if they are experiencing adverse health problems. Overall, the above symptoms can be classified into broad categories that include social problems, impaired contro, risky substance use, and physical dependence (Basedow et al., 2020). Lisa’s problems align with the above. For example, she reports using crank cocaine, smoking, and alcohol despite knowing its effects. She also spends a significant amount and time to get the substances she needs. She also has developed tolerance since she has to take the substances for her to feel high. As a result, substance use disorder is her primary diagnosis.

One of Lisa’s secondary diagnoses is post-traumatic stress disorder. Post-traumatic stress disorder is a mental disorder that arises from one’s exposure or experience of a traumatic event. The trauma predisposes them to developing symptoms such avoidance behaviors, depressed mood, flashbacks, and nightmares about their experiences (Bryant-Genevier et al., 2021; Maercker et al., 2022). Lisa has a history of being abused sexually when she was a child. As a result, she is at a risk of developing post-traumatic stress disorder. However, it is the least likely diagnosis at this stage since she does not demonstrate symptoms of the disorder such as avoidance, flashbacks, and depressed mood among others.

The last potential diagnosis that should be considered for Lisa is major depression. Major depression is a mental disorder characterized by severly depressed mood, anhedonia, social withdrawal, feelings of hopelessness, and guilt. Patients also report changes in sleep, appetite, and weight, suicidal thoughts, attempts, or plans, and poorly functioning in their social and occupational roles. Depression may be attributed to causes such as social stressors as well as substance abuse (Rice et al., 2019). However, Lisa does not demonstrate the symptoms of major depression such as depressed mood, anhedonia, and feelings of guilt and hopelessness. Therefore, major depression is the least likely cause of her mental health problem.

Reflections: I agree with the preceptor’s assessment and diagnostic impression. Lisa’s diagnosis of substance use disorder is accurate based on the criteria developed by DSMV. I learned some aspects related to mental health practice from this case study. One of them is conducting comprehensive patient assessment and psychiatric assessment. I also learned about the consideration of potential differential diagnoses and narrowing to a specific diagnosis that relates to the patient’s problem. Ethical considerations such as patient autonomy, justice, confidentiality, and privacy should guide the treatment of psychiatric patients. Social determinants such as socioeconomic status should be investigated to understand their influence on mental health problems.

References

Arterberry, B. J., Boyd, C. J., West, B. T., Schepis, T. S., & McCabe, S. E. (2020). DSM-5 substance use disorders among college-age young adults in the United States: Prevalence, remission and treatment. Journal of American College Health, 68(6), 650–657. https://doi.org/10.1080/07448481.2019.1590368

Basedow, L. A., Kuitunen-Paul, S., Roessner, V., & Golub, Y. (2020). Traumatic Events and Substance Use Disorders in Adolescents. Frontiers in Psychiatry, 11. https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00559

Bryant-Genevier, J., Rao, C. Y., Lopes-Cardozo, B., Kone, A., Rose, C., Thomas, I., Orquiola, D., Lynfield, R., Shah, D., Freeman, L., Becker, S., Williams, A., Gould, D. W., Tiesman, H., Lloyd, G., Hill, L., & Byrkit, R. (2021). Symptoms of Depression, Anxiety, Post-Traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic—United States, March–April 2021. Morbidity and Mortality Weekly Report, 70(26), 947–952. https://doi.org/10.15585/mmwr.mm7026e1

Jones, C. M., & McCance-Katz, E. F. (2019). Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and Alcohol Dependence, 197, 78–82. https://doi.org/10.1016/j.drugalcdep.2018.12.030

Maercker, A., Cloitre, M., Bachem, R., Schlumpf, Y. R., Khoury, B., Hitchcock, C., & Bohus, M. (2022). Complex post-traumatic stress disorder. The Lancet, 400(10345), 60–72. https://doi.org/10.1016/S0140-6736(22)00821-2

Rice, F., Riglin, L., Lomax, T., Souter, E., Potter, R., Smith, D. J., Thapar, A. K., & Thapar, A. (2019). Adolescent and adult differences in major depression symptom profiles. Journal of Affective Disorders, 243, 175–181. https://doi.org/10.1016/j.jad.2018.09.015