NRNP 6635 Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

NRNP 6635 Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Subjective:

CC (chief complaint):

HPI:

Ally Patel is a 48-year-old female client on psychiatric evaluation. Her school’s EAP counselor referred her for psychiatric intervention following concerns about the client’s potential substance use. Ally has been late for classes for about 22 days after engaging in excessive alcohol intake. She was referred for psychiatric care to get help for her drinking behavior and retain her in school. The client states that she was late to work on the interview day because she had attended a party the previous evening and took too much alcohol. Initially, she denies that she got drunk and passed out but admits it afterward. She admits to drinking too much alcohol every night. She mostly drinks by herself, but once in a while, she goes to a bar accompanied by her friends or drinks during school functions, where they supply alcohol liberally. Furthermore, she states that she takes 5-6 glasses of win

e and several mixed drinks when she has it rough with her students.

Ally attributes the excessive alcohol consumption to the stress she experiences at school caused by her students’

indiscipline. She takes too much alcohol but and it affects her differently, including passing out on several occasions when drunk. Students and parents have complained that the client has on several occasions taught while drunk, but she denies the allegations. Her students have complained that Ally goes to class drunk and instructs them to read from their textbook or copy notes from the board while sleeping with her head on the desk. The client’s drinking behavior is a threat to her job, and the Board of Education may dismiss her if she fails to cooperate with the psychiatric evaluation.

Past Psychiatric History:

• General Statement: No pertinent psychiatric history.
• Caregivers (if applicable): None
• Hospitalizations: No history of psychiatric hospitalization.
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: Ally started drinking alcohol when she was a teenager. Her alcohol intake has increased over the years. She takes 5-6 glasses of wine and mixed drinks every night to get intoxicated.

Family Psychiatric/Substance Use History: Ally’s father was an alcoholic. He got into Alcohol Anonymous, which helped to get sober.

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: NRNP 6635 Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Psychosocial History:

The client is an only child and was raised by parents in San Francisco, CA. She has a Ph.D. in biology and a master’s degree in high school education. She is currently a high school teacher. She is currently in a relationship.

Medical History:

 

• Current Medications: None
• Allergies: No known food or drug allergies.

• Reproductive Hx: Para 0+0; No history of gynecologic disorders.

ROS:

• GENERAL: Denies fever, chills, weight gain/loss, or fatigue.
• HEENT: Denies blurred vision, eye pain, hearing loss, ear discharge, rhinorrhea, hoarse voice, or sore throat.
• SKIN: Denies skin rashes, itching, or bruises.
• CARDIOVASCULAR: Denies palpitations, chest pain, or SOB on exertion.
• RESPIRATORY: Denies chest pain, cough, SOB, or sputum production.
• GASTROINTESTINAL: No nausea, vomiting, abdominal pain, diarrhea/ constipation, or tarry stools.
• GENITOURINARY: Denies pelvic pain, abnormal vaginal discharge, dysuria, or abnormal urine color.
• NEUROLOGICAL: Denies headache, drowsiness, fatigue, LOC, or tingling sensations.
• MUSCULOSKELETAL: No muscle pain, joint pain or stiffness, or joint enlargement.
• HEMATOLOGIC: No bruising or history of anemia.
• LYMPHATICS: Denies lymph node enlargement.
• ENDOCRINOLOGIC: Denies excessive sweating, heat/cold intolerance, polyuria, excessive hunger, or acute thirst.

Objective:

Physical exam:

Vital signs: BP: 122/76; HR- 84; RR-20; Temp- 98.24

Ht- 5’4; Wt- 138 lbs.

Diagnostic results: No diagnostic tests requested.

Assessment:

Mental Status Examination:

The patient is well-groomed and appropriately dressed for the weather. She is alert but appears confused and anxious. She maintains minimal eye contact throughout the interview. Her speech is clear, but she raises the volume when provoked. She exhibits a coherent and logical thought process. No delusions, hallucinations, obsessions, homicidal, or suicidal ideations were noted. She is oriented to person, place, and time and demonstrates good judgment. Her long-term and short-term memory is intact.

Differential Diagnoses:

Alcohol Use Disorder (AUD)

AUD is characterized by a maladaptive pattern of alcohol use that leads to clinically significant impairment or distress. Persons with AUD usually take alcohol in large amounts and over a longer period than intended (APA, 2013). There is a persistent desire or futile efforts to minimize or control alcohol use. Much time is spent in activities that seek to obtain alcohol, drink alcohol, or recover from its impact, and persons have cravings or a strong urge to take alcohol (APA, 2013). The recurrent alcohol use results in an inability to carry out duties at home, work, or school. Individuals reduce or give up important occupational, social, and recreational activities due to alcohol intake.

AUD is a differential diagnosis based on a positive history of excessive alcohol consumption and spending much time drinking alcohol. Besides, the client’s alcohol use has led to failure in carrying out her occupational obligations. She continues to take alcohol even though it causes problems at work and in her relationships.

Generalized Anxiety Disorder

GAD presents with excessive and unrealistic worry or anxiety. Other symptoms include: Restlessness or feeling keyed up or on edge, concentration difficulties, easy fatigue, muscle tension, irritability, and sleep disturbance (Bandelow et al., 2017). The patient’s history of being stressed due to student indiscipline at school could be a sign of GAD. Besides, GAD could cause excessive alcohol intake since the client takes alcohol when having a rough day with students to help her take the edge off the day (Bandelow et al., 2017). She appears anxious and is inattentive during the MSE, which are signs of GAD.

Major Depressive Disorder (MDD)

MDD presents with a depressed mood, loss of interest in activities, or both. MDD is a differential based on the patient’s report of losing interest in her job. Besides, her alcohol problem could be caused by depression (McHugh & Weiss, 2019). Nonetheless, she does not exhibit other symptoms of MDD, making an unlikely diagnosis.

Reflections:

If I were to conduct the assessment again, I would inquire if the patient uses other drug substances to identify if she has a substance abuse disorder(Kranzler & Soyka, 2018). Ethical considerations for this client include beneficence, nonmaleficence, and confidentiality. Beneficence and nonmaleficence should be maintained by implementing evidence-based treatment interventions to promote the best possible health outcomes (Bipeta, 2019). Besides, the interventions should be evaluated beforehand to ensure they are safe and not harm the client. Confidentiality is crucial, and the mental health provider should uphold it by seeking the client’s consent before sharing her information with others (Bipeta, 2019). Health promotion should center on educating the client on interventions she should take to lower her alcohol intake.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review. JAMA, 320(8), 815–824. https://doi.org/10.1001/jama.2018.11406

McHugh, R. K., & Weiss, R. D. (2019). Alcohol Use Disorder and Depressive Disorders. Alcohol research: current reviews, 40(1), arcr.v40.1.01. https://doi.org/10.35946/arcr.v40.1.01

Subjective:

CC (chief complaint): Client’s supervisor, “Ms. Ally’s alcohol consumption, is getting out of

hand. I suspect a potential substance use.”

HPI:

Ally is a 48-year-old female who is undergoing psychiatric assessment after a referral from the school EAP counselor as a result of her substance abuse probability. The client has been late for classes for 22 days due to excessive alcohol consumption and was referred to facilitate getting her help and retaining her at the school. The patient reports that she was late to work on the interview day since she attended a party the previous evening and drank too much. She initially denies that she got intoxicated and passed out but later admits it. The client reports that she drinks too much every night. She states that she mostly drinks alone but occasionally goes to a bar with her friends or drink at school functions, where the alcohol supply is liberal. She also reports taking 5-6 glasses of wine and several mixed drinks when her students give her a rough time.

The client attributes the excessive drinking to the stress she experiences at school due to students’ indiscipline. She admits to taking too much alcohol but states that it affects her differently. She admits to passing out severally when drunk. Students and parents have complained that Ally has severally gotten to class to teach while drunk, but she denies the claims. According to her students, she goes to class drunk and orders them to read from their textbook or copy notes from the board while sleeping with her head on the desk. Her drinking behavior puts her at risk of losing her teaching job, and the Board of Education may dismiss her if she does not cooperate during the psychiatric evaluation.

Past Psychiatric History:

• General Statement: No psychiatric history.
• Caregivers: None
• Hospitalizations: No history of psychiatric hospitalization.
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History:

She has a history of alcohol consumption since she was a teenager. Alcohol consumption has increased over the years. She reveals taking on average 5 wine glasses alongside some mixed drinks in order to get high. She takes 5-6 glasses of wine and a handful of mixed drinks to get intoxicated.

Family Psychiatric/Substance Use History: The client’s father was an alcoholic. He got into Alcohol Anonymous and quit alcohol.

Psychosocial History:

Ally was born alone and her parents raised her within the San Francisco area in Carlifonia. She possesses a PhD majoring in Biology while also having a Masters in high school education. Her current employment is in high school. Ally reports being currently in a relationship.

Medical History:

 

• Current Medications: None
• Allergies: No food or drug allergies.

• Reproductive Hx: Para 0+0; No history of gynecologic disorders. LMP-3 weeks ago.

ROS:

• GENERAL: Lacks chills, fever, fatigue or weight changes.
• HEENT: Denies traumatic head injury, eye pain, blurred vision, ear discharge, hearing loss, sneezing, nasal discharge, sore throat, or hoarse voice.
• SKIN: Negative for skin rashes, itching, bruises, or lesions.
• CARDIOVASCULAR: Denies palpitations, chest pain, SOB on exertion, orthopnea, or edema
• RESPIRATORY: Does not have cough, sputum production, dyspnea, or chest pain.
• GASTROINTESTINAL: Denies rectal bleeding, vomiting, nausea, constipation, abdominal discomfort, or diarrhea.
• GENITOURINARY: Negative for pelvic pain, excessive or malodorous vaginal discharge, dysuria, or urine color changes.
• NEUROLOGICAL: Negative for headache, fatigue, drowsiness, LOC, or burning sensations.
• MUSCULOSKELETAL: Denies muscle pain, joint pain/stiffness, or joint enlargement.
• HEMATOLOGIC: Denies bruising or history of blood transfusion.
• LYMPHATICS: Does not have a history of lymph node enlargement.
• ENDOCRINOLOGIC: Rejects excessive hunger, polyuria, and thirst, or excessive sweating.

Objective:

Physical exam:

BP: 122/76; HR- 84; RR-20; Temp- 98.24

Ht- 5’4; Wt- 138 lbs.

Diagnostic results: No labs or imaging tests were ordered.

Assessment:

Mental Status Examination:

The client is neat and dressed appropriately for the weather and function. She is alert but appears a bit confused and anxious and maintains limited eye contact. Her speech is clear at a normal rate, but the volume increases when she gets provoked. She demonstrates a congruent thought process. No hallucinations, delusions, obsessions, homicidal, or suicidal ideations were noted. She is oriented to time, person, and place, and also manifests good judgment. Memory is intact. Insight is present.

Differential Diagnoses:

Alcohol Use Disorder

Alcohol use disorder (AUD) is defined to as a maladaptive pattern associated with substance use that leads to the clinical impairment or distress of an individual. According to the DSM-V, the presence of certain symptomatology such as extended alcohol use in large amounts, inability to reduce alcohol intake, expending time on alcohol related activities, and craving for alcohol indicate the condition (APA, 2013). Moreover, using the alcohol recurrently thus impairing social and economic functions and the usage of alcohol despite its social detriments also lend to the presence of alcohol use disorder (Yang et al., 2018). Besides, fundamental occupational, social, or recreational activities are given up or reduced due to imbibing on alcohol. Lastly, obsession with alcohol does not reduce despite its exacerbation of physical or psychological manifestations.

AUD is a differential diagnosis based on the client’s history of taking large amounts of alcohol; Spending lots of time taking alcohol; recurrent alcohol use resulting in failure to carry out her teaching obligations; and continuing to take alcohol despite it causing problems in her relationships.

Generalized Anxiety Disorder

The client could be having GAD based on her report of getting stressed due to student indiscipline at school. The alcohol intake could result from GAD since she reports taking alcohol when her students take the edge off the day (McHugh & Weiss, 2019). Besides, the client appears anxious and is inattentive during the interview, which is consistent with GAD.

Major Depressive Disorder

Major depressive disorder (MDD) is a differential diagnosis based on the client’s history of losing interest in her job. The client’s alcohol problem could be secondary to depression (McHugh & Weiss, 2019). However, she does not demonstrate other symptoms of MDD.

Reflections:

If I were to conduct the session again, I would assess the client’s history of using other drug substances to rule out the presence of a substance abuse disorder. I would also order a urine test to evaluate if the client has been using other illicit drugs (Kranzler & Soyka, 2018). Legal and ethical considerations for this client include autonomy, beneficence, nonmaleficence, and confidentiality. The PMHNP should respect the client’s decision regarding her care to uphold autonomy.  Beneficence and nonmaleficence should be upheld by choosing treatment interventions to promote the best possible health outcomes and not harm the client. In addition, the PMHNP should ensure that the client’s information is not shared with other persons without the client’s consent. The client’s health promotion strategies should focus on reducing alcohol consumption and help her return to normal functioning.

 

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review. JAMA, 320(8), 815–824. https://doi.org/10.1001/jama.2018.11406

McHugh, R. K., & Weiss, R. D. (2019). Alcohol Use Disorder and Depressive Disorders. Alcohol research: current reviews, 40(1), arcr.v40.1.01. https://doi.org/10.35946/arcr.v40.1.01

Yang, P., Tao, R., He, C., Liu, S., Wang, Y., & Zhang, X. (2018). The Risk Factors of the Alcohol Use Disorders-Through Review of Its Comorbidities. Frontiers in neuroscience, 12, 303. https://doi.org/10.3389/fnins.2018.00303

CC (chief complaint): “I have come for a prescription for oxycodone.”

HPI: Daniela Petrov is a 47-year-old Russian female who presented to her family physician for an oxycodone prescription to alleviate elbow pain. The family physician referred her for psychiatric evaluation due to concerns that the oxycodone can interact with some drugs Daniela is taking. The client states that the elbow pain is only alleviated by oxycodone, which also relieves her headaches. Daniela reports that other pain medications were ineffective, including Ibuprofen, acetaminophen, morphine, codeine, and Dilaudid. Non-pharmacological approaches like massage, Yoga, and meditation are also ineffective. She reports that she dislikes taking multiple medications because they are not good for her body and prefers taking one medication. The client has never been prescribed oxycodone and has been taking her boyfriend’s prescription, which he uses for shoulder and back pain.

Past Psychiatric History:

• General Statement: The patient first presented for psychiatric assessment following concerns about misusing oxycodone.
• Caregivers (if applicable): None
• Hospitalizations: None
• Medication trials: Previously used Klonopin, Ativan, and Xanax for Anxiety.
• Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History:

The client takes alcohol on special occasions average twice a week and on special occasions. She uses Marijuana 2-4 times a week since it helps alleviate headaches. Besides, she used cocaine about two months ago to ease anxiety and get closer to her boyfriend. The patient has used Ecstasy and LSD 1-2 times in the past year. She smokes tobacco 2PPD and takes lots of caffeine. She occasionally takes stimulants, like Adderall and Xana bars, to ease anxiety.

Family Psychiatric/Substance Use History: No history of mental health or substance use disorders in the family.

Psychosocial History:

Daniela was born in Russia and moved to Everett, WA, with her parents when she was 16. She has three older sisters and one younger brother. She has a part-time job as a cashier at Save A Lot Grocery Store. She studied up to 10^th grade and dropped out after that. The client has one son who currently lives with the ex-husband’s parents. She lost her son’s custody after her boyfriend was detained for selling marijuana to an undercover cop. She averagely sleeps 5–6 hours and has a good appetite. She has a legal history because of over-speeding while under the influence of alcohol and using marijuana.

Medical History:

 

• Current Medications: Oxycodone and Vitamin supplements.
• Allergies: Allergic to Codeine- causes flushing.

• Reproductive Hx: Regular menses; uses condoms for contraception.

ROS:

• GENERAL: Denies fever or weight changes.
• HEENT: Denies vision change, eye pain, hearing loss, rhinorrhea, or sore throat SKIN: No rashes, discoloration, or lesions.
• CARDIOVASCULAR: No palpitations, chest pain, edema, or breathlessness.
• RESPIRATORY: No breathlessness, wheezing, or productive cough.
• GASTROINTESTINAL: No anorexia, abdominal cramping, diarrhea, constipation, or tarry stools.
• GENITOURINARY: Regular menses. No vaginal or urinary symptoms.
• NEUROLOGICAL: Reports headache and memory loss. No fainting or numbness.
• MUSCULOSKELETAL: Reports elbow pain and fibromyalgia.
• HEMATOLOGIC: No bleeding or bruising.
• LYMPHATICS: No swelling of lymph nodes.
• ENDOCRINOLOGIC: No profuse sweating, polyphagia, polydipsia, polyuria, or heat/cold intolerance.

Physical exam:

Vital Signs: BP- 132/90; HR- 84; RR- 20; Temp-98.8; Ht 5’8; Wt 128lbs

Diagnostic results: No tests were ordered.

Assessment

Mental Status Examination:

A female client in her late 40’s; is alert, well-groomed, and dressed appropriately. The client has clear speech with normal volume, rate, and tone. She has a coherent and logical thought process. She has no hallucinations, delusions, phobias, obsessions, suicidal thoughts, or ideations. She is alert and oriented to person, place, time, and event. She has sound judgment and intact short-term memory.

Differential Diagnoses:

Opioid Use Disorder (OUD): OUD is the compelling, long-term self-administration of opioids for non-medical uses. Patients with OUD take opioids in large amounts or for a longer period than purposed. They constantly desire or unsuccessfully attempt to reduce opioid use, craving for opioids, and develop tolerance to opioids (Hoffman et al.,2019). Besides, they use opioids in physically hazardous conditions and repeatedly fail to meet social and occupational obligations due to opioids (Strang et al., 2020). OUD is a likely diagnosis considering the client’s history of self-prescribing oxycodone for elbow pain and headaches. She has persistently used oxycodone resulting in dependency and cannot benefit from other analgesics.

Cannabis Use Disorder: Cannabis Use Disorder is characterized by persistent use of cannabis in spite of impairment in physical, psychological, or social functioning. Patients often take cannabis in large amounts or over an extended period than intended and have cravings. They also use cannabis in physically hazardous environments and develop tolerance with the need for increased amounts of cannabis to get the intoxicated or desired effect (Hasin & Walsh, 2020). Cannabis Use Disorder is a differential owing to the patient’s increased use of Marijuana 2-4 times a week and misusing it to relieve headaches. Besides, she continues to use cannabis despite being previously arrested for using the substance.

Stimulant Use Disorder: This is a substance use disorder involving drug classes like methamphetamine, cocaine, and prescription stimulants. Patients lose control, evidenced by taking stimulants in large amounts or for extended periods than intended, and have cravings or a powerful desire to use stimulants. They also have risky use of stimulants like continued use, even with associated physical or psychological problems (Ronsley et al., 2020). The use often causes social impairment. The patient has a history of using cocaine, Adderall, LSD, and high amounts of caffeine, making Stimulant Use Disorder a likely diagnosis.

Reflections:

In a different scenario, I would order a drug screen test to identify the drug substances the patient has been using. I will also inquire if the patient develops withdrawal symptoms (Krist et al., 2020). In addition, I would assess the patient for anxiety disorder owing to her history of using substances to ease anxiety. The PMHNP should consider ethical factors of beneficence and nonmaleficence by ensuring treatment interventions are established to promote better outcomes and are safe in patients with substance use disorders. Health promotion should be tailored for this client to educate her adverse effects of substance use and the resources available to help individuals with SUDs(Krist et al., 2020). She should be educated about the risks of using substances for her mental and overall health and well-being.

 

References

Hasin, D., & Walsh, C. (2020). Cannabis use, cannabis use disorder, and comorbid psychiatric illness: a narrative review. Journal of Clinical Medicine, 10(1), 15. https://doi.org/10.3390/jcm10010015

Hoffman, K. A., Ponce Terashima, J., & McCarty, D. (2019). Opioid use disorder and treatment: challenges and opportunities. BMC health services research, 19(1), 884. https://doi.org/10.1186/s12913-019-4751-4

Krist, A. H., Davidson, K. W., Mangione, C. M., Barry, M. J., Cabana, M., Caughey, A. B., … & US Preventive Services Task Force. (2020). Screening for unhealthy drug use: US Preventive Services Task Force recommendation statement. Jama, 323(22), 2301-2309. doi:10.1001/jama.2020.8020

Ronsley, C., Nolan, S., Knight, R., Hayashi, K., Klimas, J., Walley, A., Wood, E., & Fairbairn, N. (2020). Treatment of stimulant use disorder: A systematic review of reviews. PloS one, 15(6), e0234809. https://doi.org/10.1371/journal.pone.0234809

Strang, J., Volkow, N. D., Degenhardt, L., Hickman, M., Johnson, K., Koob, G. F., … & Walsh, S. L. (2020). Opioid use disorder. Nature reviews Disease primers, 6(1), 1-28. https://doi.org/10.1038/s41572-019-0137-5