Assignment: Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders
As an advanced practice nurse, it is important to know how to assess and diagnose patients with substance-related and addictive disorders. To prepare for the assignment, you should review the learning resources provided and become familiar with the Comprehensive Psychiatric Evaluation template. You should also identify a video case study to use for the assignment, view the assigned video case, and review the additional data provided in the “Case History Reports” document. You should consider what history would be necessary to collect from the patient and what interview questions would be needed to ask the patient. Finally, you should identify at least three possible differential diagnoses for the patient.
Steps to Consider in Writing the Assignment: Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders
To begin, review the Comprehensive Psychiatric Evaluation template provided below and familiarize yourself with the criteria for diagnosing substance-related and addictive disorders as outlined in the DSM-5. Select a video case study from the choices provided and review the patient’s case history report, paying attention to any cultural or contextual factors that may be relevant to the assessment and diagnosis process.
Next, consider what questions you would need to ask the patient during an interview to gather the necessary information for a comprehensive psychiatric evaluation. Take note of the patient’s chief complaint, symptomatology, and the duration and severity of their symptoms, as well as how their symptoms are impacting their daily functioning.
Based on your assessment, formulate at least three possible differential diagnoses, listed in order of priority, and provide supporting evidence for each diagnosis. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain how you ruled out each diagnosis to arrive at your primary diagnosis. Be sure to include pertinent positives and negatives that support your diagnosis, taking into consideration any cultural, social, or economic factors that may be relevant.
Finally, in your reflection notes, consider how you would approach the session differently if given the opportunity and discuss any legal or ethical considerations related to the patient’s treatment. Consider how you might incorporate health promotion and disease prevention strategies into your treatment plan, taking into account the patient’s age, ethnicity, and other risk factors.
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Comprehensive Psychiatric Evaluation Template
Patient Information:
Name: ___________ Date of Birth: ___________ Date of Evaluation: ___________
Identifying Data:
The patient is a _____-year-old (gender) (ethnicity) individual who presents with (chief complaint) and reports a history of (relevant medical and psychiatric history).
Reason for Referral:
The patient was referred for evaluation due to (reason for referral).
Subjective:
The patient reports experiencing (symptoms) for (duration). The symptoms have impacted the patient’s functioning in (specific areas of life).
Mental Status Examination:
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Process:
Thought Content:
Perception:
Cognition:
Insight:
Judgment:
Assessment:
Based on the patient’s history and mental status examination, the following differential diagnoses are considered:
- (Differential Diagnosis 1) – (Supporting Evidence)
- (Differential Diagnosis 2) – (Supporting Evidence)
- (Differential Diagnosis 3) – (Supporting Evidence)
After considering the DSM-5 diagnostic criteria, (Differential Diagnosis #) can be ruled out because (reason). The critical-thinking process led to the primary diagnosis of (Primary Diagnosis).
Pertinent Positives:
Pertinent Negatives:
Plan:
The following plan is recommended for the patient:
- (Interventions)
- (Referrals)
- (Follow-up)
Reflection:
If I could conduct the session over, I would (reflection). In terms of legal/ethical considerations, (discussion). In terms of health promotion and disease prevention, (discussion).
Assignment: Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders Example One
Patient Name: John Doe
Age: 32
Gender: Male
Date of Evaluation: 03/13/2023
Identifying Information
The patient is a 32-year-old male who was brought in for evaluation by his wife due to his recent drug use and erratic behavior. He is currently unemployed and lives with his wife and two children.
Chief Complaint
The patient’s chief complaint is “I can’t stop using drugs.”
History of Present Illness
The patient reports that he has been using heroin for the past year, and he has been experiencing intense cravings and withdrawal symptoms when he tries to quit. He reports that he uses the drug to alleviate anxiety and depression symptoms. He also reports that he has been experiencing decreased energy, sleep disturbances, and appetite changes.
Mental Status Examination
The patient was cooperative and communicative during the evaluation. His mood was depressed, and his affect was constricted. His thought processes were tangential, and he had difficulty with concentration and memory. He denied suicidal or homicidal ideation.
Diagnostic Impressions
- Substance Use Disorder
- Major Depressive Disorder
- Generalized Anxiety Disorder
Assessment
The patient’s substance use disorder is the primary diagnosis. The DSM-5 criteria for substance use disorders include the presence of impaired control, social impairment, risky use, and pharmacological criteria. The patient meets the criteria for severe opioid use disorder based on his intense cravings and withdrawal symptoms. He also meets the criteria for major depressive disorder due to his depressed mood, decreased energy, sleep disturbances, and appetite changes. Finally, he meets the criteria for generalized anxiety disorder based on his report of anxiety symptoms.
Differential Diagnosis
- Substance-induced mood disorder
- Bipolar disorder
- Adjustment disorder with mixed anxiety and depressed mood
The differential diagnoses were considered based on the patient’s depressive symptoms, but the DSM-5 criteria for each diagnosis were ruled out based on the patient’s history and current symptoms.
Critical-Thinking Process
The primary diagnosis of substance use disorder was selected based on the DSM-5 criteria and the patient’s history of heroin use, intense cravings, and withdrawal symptoms. The secondary diagnoses of major depressive disorder and generalized anxiety disorder were also made based on the patient’s reported symptoms.
Reflection Notes
If I could conduct the session over, I would spend more time discussing the patient’s social history and family dynamics to better understand his support system and potential sources of stress. Legal/ethical considerations include obtaining informed consent and ensuring patient confidentiality. Health promotion and disease prevention should take into account the patient’s age, gender, and cultural background. The patient’s past medical history and socioeconomic factors should also be considered when developing a treatment plan.
Assignment: Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders Example Two
Patient Information
Name: Briana Jackson
Age: 27
Gender: Male
Ethnicity: African American
Date of Evaluation: 03/13/2023
Chief Complaint
“I feel like I can’t go a day without using cocaine. It’s really affecting my life, and I’m starting to worry about my health.”
History of present illness (HPI)
Briana Jackson is a 27-year-old African American male who presents with concerns about cocaine use. He reports that he has been using cocaine regularly for the past two years, with increasing frequency over the past six months. He reports using cocaine daily, and has attempted to cut back or stop using in the past, but has been unsuccessful. He reports feeling like he needs cocaine to function, and that his cocaine use has impacted his work, relationships, and overall functioning. He reports no significant past medical history and no other current medical concerns.
Mental Status Examination
Appearance: Briana is a well-groomed African American male, who appears alert and oriented.
Speech: Briana’s speech is clear and coherent, with no evidence of slurring or difficulty with articulation.
Mood/Affect: Briana’s mood is anxious, and his affect is dysphoric.
Thought Content: Briana reports feeling like he needs cocaine to function, and expresses concern about the impact of his cocaine use on his life.
Thought Process: Briana’s thought process is organized and goal-directed, with no evidence of tangential thinking or loose associations.
Perception: No evidence of perceptual disturbances.
Cognition: Briana is alert and oriented to person, place, and time. He reports no difficulty with memory or concentration.
Differential Diagnosis
- Cocaine use disorder
- Generalized anxiety disorder
- Major depressive disorder
To arrive at the primary diagnosis of cocaine use disorder, I considered several factors. Briana meets the DSM-5 criteria for cocaine use disorder, including a pattern of use that has persisted for more than 12 months, unsuccessful attempts to cut down or stop using, and impairment in social, occupational, and/or other areas of functioning. Additionally, Briana reports feeling like he needs cocaine to function, which is consistent with the diagnosis of a substance use disorder. Briana also reports anxious and dysphoric mood, which could suggest co-occurring anxiety or depressive disorders. However, these symptoms could also be secondary to the effects of cocaine use. While Briana meets the diagnostic criteria for both generalized anxiety disorder and major depressive disorder, these diagnoses are less likely given the context of his symptoms and the evidence of cocaine use disorder.
Reflection Notes
If I could conduct the session over, I would make sure to spend more time exploring the impact of Briana’s cocaine use on his relationships, work, and overall functioning. Additionally, I would try to better understand his motivation for seeking treatment at this time, and explore potential barriers to treatment engagement. In terms of legal/ethical considerations, I would make sure to discuss the risks and benefits of treatment options, including the use of medication-assisted treatment for cocaine use disorder. I would also consider factors such as Briana’s cultural background and socioeconomic status in developing a treatment plan that is appropriate for him. Finally, I would emphasize the importance of ongoing monitoring and support to prevent relapse and promote long-term recovery.
Assignment: Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders Example Three
Patient Name: John Smith
Age: 42
Gender: Male
Date of Evaluation: 03/13/2023
SUBJECTIVE:
The patient, John Smith, presents with a chief complaint of feeling anxious and depressed for the past few months. He reports feeling “down” and “hopeless” most of the time and has trouble sleeping. He admits to using cocaine and alcohol frequently to cope with his symptoms. He reports experiencing tremors and sweating when he tries to stop using substances. John reports that his symptoms have been interfering with his work and relationships, causing significant distress.
OBJECTIVE:
During the evaluation, John appeared anxious and restless, fidgeting in his seat and avoiding eye contact. He had dilated pupils and slight tremors in his hands. His speech was rapid and pressured, and he exhibited psychomotor agitation.
ASSESSMENT:
Mental Status Examination Results:
- Appearance and behavior: The patient appeared anxious and restless, exhibiting psychomotor agitation.
- Mood and affect: The patient’s mood was depressed and hopeless, and his affect was constricted.
- Thought process: The patient’s thought process was rapid and pressured.
- Thought content: The patient expressed feelings of hopelessness and despair.
- Perception: No evidence of perceptual disturbances.
- Cognition: The patient’s cognitive functioning appeared to be intact, with no evidence of memory impairment or disorientation.
- Insight and judgment: The patient had limited insight into his condition and was reluctant to engage in treatment.
Differential Diagnosis:
- Cocaine Use Disorder: The patient exhibits the following symptoms that meet the criteria for Cocaine Use Disorder according to DSM-5: tolerance, withdrawal, and use of the substance in larger amounts or for a longer period than intended. The patient has been using cocaine frequently to cope with his symptoms, which has resulted in functional impairment.
- Alcohol Use Disorder: The patient exhibits the following symptoms that meet the criteria for Alcohol Use Disorder according to DSM-5: tolerance, withdrawal, and use of the substance in larger amounts or for a longer period than intended. The patient reports using alcohol frequently to cope with his symptoms, which has resulted in functional impairment.
- Major Depressive Disorder: The patient exhibits the following symptoms that meet the criteria for Major Depressive Disorder according to DSM-5: depressed mood, anhedonia, insomnia, feelings of worthlessness or guilt, and thoughts of death or suicide.
Critical Thinking Process:
Based on the patient’s history, symptoms, and observations during the evaluation, the primary diagnosis for John is Cocaine Use Disorder. While he also exhibits symptoms of Alcohol Use Disorder and Major Depressive Disorder, his cocaine use appears to be the primary driver of his functional impairment and overall distress. The patient reports experiencing withdrawal symptoms, including tremors and sweating, when he tries to stop using cocaine. Additionally, his physical examination revealed dilated pupils and slight tremors, which are consistent with cocaine use.
Reflected Notes:
If I could conduct the session over, I would spend more time exploring the patient’s social support system and possible underlying stressors. It is also important to address any legal or ethical considerations related to the patient’s substance use, such as driving under the influence or workplace policies. Health promotion and disease prevention strategies should also be discussed, including harm reduction techniques and referral to substance use treatment programs. Finally, cultural and socioeconomic factors should be considered when developing a treatment plan that is tailored to the patient’s unique needs and circumstances.
Assignment: Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders Example Four
Patient Information:
Name: Bob
Age: 34
Sex: Male
Occupation: Unemployed
Education: High School
Marital Status: Single
Ethnicity: African American
Chief Complaint:
Bob complains of difficulty controlling his alcohol consumption.
HPI:
Bob reports that he started drinking heavily in college but was able to keep it under control until recently. He now drinks every day and cannot control the amount he consumes. He reports experiencing tremors in his hands and sweating when he does not drink.
Past Psychiatric History:
Bob reports a history of depression and anxiety for which he was prescribed medication but stopped taking it due to side effects.
Medication Trials and Current Medications:
Bob reports taking no current medications.
Psychotherapy or Previous Psychiatric Diagnosis:
Bob reports receiving a diagnosis of depression and anxiety in the past but has not received any psychotherapy.
Pertinent Substance Use, Family Psychiatric/Substance Use, Social, and Medical History:
Bob reports a family history of alcoholism. He also reports experiencing financial difficulties and losing his job due to his drinking.
Allergies:
Bob reports no known allergies.
ROS:
Bob reports no significant changes in his weight, appetite, or sleep patterns.
Mental Status Exam:
Bob presents as a disheveled and unkempt individual. He appears agitated and restless, frequently shifting in his seat. His speech is slurred, and he has difficulty focusing on the questions asked. He reports experiencing auditory hallucinations.
Assessment:
Based on Bob’s history and mental status exam, the following differential diagnoses are possible:
- Alcohol use disorder
- Major depressive disorder with psychotic features
- Schizophrenia
Alcohol use disorder is the highest priority diagnosis. The DSM-5 criteria for alcohol use disorder include a problematic pattern of alcohol use leading to clinically significant impairment or distress, such as drinking more than intended or being unable to stop or cut down on drinking. Bob meets these criteria, as he reports difficulty controlling his alcohol consumption and experiencing withdrawal symptoms when he attempts to stop.
Major depressive disorder with psychotic features is another possible diagnosis, as Bob reports a history of depression and currently experiences auditory hallucinations. However, his symptoms are more consistent with alcohol use disorder.
Schizophrenia is a less likely diagnosis, as Bob does not report a history of psychotic symptoms outside of his alcohol use.
The critical-thinking process that led to the primary diagnosis of alcohol use disorder was based on Bob’s history of heavy drinking, withdrawal symptoms, and difficulty controlling his alcohol consumption, which all meet the DSM-5 criteria for alcohol use disorder.
Reflection Notes:
If I could conduct the session over, I would focus more on exploring Bob’s feelings and motivations for drinking to gain a better understanding of his behavior. I would also address his auditory hallucinations and explore the possibility of comorbid psychiatric disorders. Legal and ethical considerations include ensuring informed consent and confidentiality, as well as addressing any potential risks associated with Bob’s heavy drinking, such as impaired judgment and increased risk of accidents. Health promotion and disease prevention would include addressing the long-term health consequences of alcohol use disorder and providing resources for quitting drinking. Factors such as Bob’s age, ethnicity, and socioeconomic background may also impact his treatment plan and should be taken into consideration.
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