Week 8 Assignment: Substance-Related and Addictive Disorders

 Week 8 Assignment: Substance-Related and Addictive Disorders

 Week 8 Assignment: Substance-Related and Addictive Disorders

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.

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In the Subjective section, provide:

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• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
• Read rating descriptions to see the grading standards!

In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
• Read rating descriptions to see the grading standards!

In the Assessment section, provide:

• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least 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.
• Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation.  Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS.  The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5-TR diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level

Hobbies:

Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnostic impression selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

A Sample Of This Assignment Written By One Of Our Top-rated Writers

Week 8: Substance-Related and Addictive Disorders

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

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