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

Subjective:

CC (chief complaint): ‘I am scared. I don’t want to be what people say I am because I ant going to change. I can’t.’

HPI: Lisa is a 29-year-old female that is in West Palm Beach, FL detox facility thinking about long-term rehab. Lisa has a history of smoking crack cocaine, cannabis, and taking alcohol. She reports smoking crack cocaine for approximately $100 daily, cannabis 1-2 times weekly, and alcohol 2-3 drinks weekly. Lisa reports that she fears being admitted to rehab due to fear of stigmatization and difficulties in being employed thereafter. Lisa has a history of theft convictions and drug possession. She is on 2-year probation with randomized drug screens. She has been trying to find a pattern for the calls for her not to test dirty urine. Lisa reports that the use of crack cocaine relieves her distressing experience due to cocaine addiction.

Past Psychiatric History:

General Statement: ‘I am scared. I don’t want to be what people say I am because I ain’t going to change. I can’t.’
Caregivers (if applicable): none
Hospitalizations: no history of hospitalizations provided.
Medication trials: no history of medication trials.
Psychotherapy or Previous Psychiatric Diagnosis: No history of previous psychotherapy. Lisa has a history of substance abuse disorder, as she has past drug possessions and theft convictions. She is also currently on 2-year probation with randomized drug screens.

Substance Current Use and History: Lisa has a history of smoking crack cocaine approximately $100 daily, cannabis 1-2 times weekly, and 2-3 alcohol drinks once weekly.

Family Psychiatric/Substance Use History: There is positive substance abuse and psychiatric conditions in the family. Lisa’s mother has a history of anxiety and the use of benzodiazepine. Lisa’s brother has a history of opioid use. Her father has a history of drug abuse and is currently in prison for sexually abusing her.

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

Psychosocial History: Lisa currently lives with her boyfriend, Jeremy. She has a daughter who lives with her friends. She is employed in a hospital where she has been using drugs to avoid being identified to be suffering from substance abuse disorder. She lives with her boyfriend in a rented house. Lisa fears the stigmatization that she would experience should she be admitted to the rehab.

Medical History:

Current Medications: Lisa is currently not on any medications
Allergies: Lisa is allergic to amoxicillin. She does not have any allergy to food or environmental agents such as pollen.
Reproductive Hx: Lisa has one daughter who currently lives with her friends. She is sexually active, as she lives with her boyfriend, Jeremy. Any other significant reproductive history is not given.

ROS:

GENERAL: The patient appears well-groomed for the occasion. She appears slightly underweight compared to individuals of her age. She demonstrates mild tremors of the upper extremities. She denies fever or child.

HEAD/NECK: The client denied lymphadenopathy, neck pain, rigidity, distended veins, and pain in swallowing. The head is normocephalic with no evidence of trauma or unequal hair distribution
EYES: The client denied vision changes, drainage, pain, or double vision. She does not use corrective lenses.
EARS/NOSE/MOUTH/THROAT: The patient denied changes in hearing, ear drainage, ear pain, and infections. She also denied nasal congestion, drainage, and nose bleeds. She denied halitosis, difficulties in swallowing, bleeding gums, sore throat, and sore tongue.
CARDIOVASCULAR: The client denied chest pain and palpitations.
PULMONARY: The client denied shortness of breath, cough, dyspnea, wheezing, and chest pain.
GASTROINTESTINAL: The client denied abdominal tenderness, constipation, diarrhea, and bloating.
GENITOURINARY: The client denied urinary incontinence, painful urination, and increased frequency of urination.
MUSCULOSKELETAL: The patient denied muscle pain, fractures, tenderness, and muscle weakness.
INTEGUMENTARY: The client denied rashes, lumps, bruises, and lacerations.
NEUROLOGICAL: The client reported the presence of upper arm tremors. She denied headache, dizziness, vomiting, and nausea.
PSYCHIATRIC: The client has a history of substance abuse disorder.
ENDOCRINE: The client denied cold or heat intolerance, polydipsia, and polyphagia.
HEMATOLOGIC/LYMPHATIC: The patient denied lymphadenopathy.
ALLERGIC/IMMUNOLOGIC: The client denied any history of food or environmental allergies. She is allergic to amoxicillin.

Objective: T-99.8, P-101, R-20, BP 178/94, Ht-5’6, Wt-140lbs

Physical exam: if applicable

Diagnostic results: Lisa’s admission lab works were done. The results were abnormal for ALT 168, AST 200, ALK 250, bilirubin 2.5, albumin 3.0, and GGT 59. UDS was positive for cocaine, and THC. It was negative for alcohol or other drugs. Other labs were within the normal range with BAL being 3.0.

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Assessment:

Mental Status Examination: Lisa is a 29-year old female who appears dressed for the occasion. She oriented to self, time, space, and events. She demonstrates mild tremors of the upper limbs. She appears anxious and fearful about being in rehab. Lisa denies illusions, delusions, and hallucinations. Her thought process is intact. She demonstrates the repetition of words during the assessment. She does not have suicidal thoughts, plans, or attempts.

Differential Diagnoses:

Substance use disorder: Lisa’s primary diagnosis is substance use disorder. According to DSMV, substance use disorders arise from the use of drugs that include cannabis, caffeine, hallucinogens, inhalants, sedatives, opioids, anxiolytics, stimulants, and tobacco among others. A patient is diagnosed with the disorder if he presents with specific complaints. They include taking the drug in larger quantities or for a prolonged duration, wanting to stop or cut down the drug or substance but unsuccessful, and spending too much time in getting, using, or recovering from the substance (Proctor et al., 2019). It also includes suffering from urges or cravings for the drug, failing to perform in social and occupational roles due to substance use, and continuing substance use despite affecting relationships and performance. Patients must also give up their social and occupational activities for the substance, using the substance despite putting them in danger, and needing more of the drug to achieve the desired effect. Patients also develop withdrawal symptoms if they stop taking the drug, which can be relieved by taking the drug (John et al., 2018). Lisa meets most of the above criteria for being diagnosed with substance use disorder. She uses caffeine, cannabis, and alcohol. She also depends on caffeine to function optimally. Lisa is aware of the negative effects of substance abuse and has not its use despite being informed about its effects. Substance abuse has also affected her occupational functioning, roles, and success of their business and relationships. Therefore, substance use disorder is Lisa’s primary diagnosis.
Generalized anxiety disorder: Generalized anxiety disorder is the secondary diagnosis that should be considered for Lisa. According to DSMV, patients are diagnosed with an anxiety disorder if they experience excessive anxiety and worry that cause behavioral disturbances. The excessive fear and worry should occur for at least six months with patients finding it hard to control their emotions. The accompanying symptoms include being restless, easily fatigued, irritable, and experiencing sleep disturbances and muscle tension (Munir et al., 2022). Lisa reports fear of rehab and the stigma associated with rehabilitation. As a result, the fear that she experiences does not qualify her to be diagnosed with a generalized anxiety disorder since it has not occurred for a long period and is not associated with any of the above accompanying symptoms.
Post-traumatic stress disorder: The other secondary differential that should be considered for Lisa is post-traumatic stress disorder. Post-traumatic stress disorder is mainly diagnosed in individuals with traumatic experiences (Price et al., 2019). The DSMV sets criteria that should be met for a patient to be diagnosed with post-traumatic stress disorder. They include direct or indirect exposure to traumatic events and symptoms that include intrusion, negative changes in mood and thoughts, avoidance, and changes in reactivity and arousal. The symptoms should persist for at least one month and cause significant interference with life or distress. The symptoms should not be attributable to other causes such as medical conditions, medication use, and substance abuse (Carmassi et al., 2020). Lisa has a traumatic experience of being sexually abused by her father. However, the traumatic experience does not cause symptoms that include avoidance, intrusion, changes in mood and thought processes, reactivity, and arousal, hence, it is the least likely diagnosis for her.

Reflections: Lisa’s case study has increased my understanding of substance abuse disorders. It expanded my understanding of the different symptoms and criteria that should be considered in diagnosing patients with the disorder. I believe that I developed an accurate diagnosis for the patient. One of the things that I would do differently should I encounter a similar patient is to explore the social factors that influence substance abuse. Social factors such as unstable families and peer pressure may affect clients’ efforts to abstain from substances (Sliedrecht et al., 2019). As a result, exploring them would inform the adoption of effective treatment interventions. Ethical considerations that include the promotion of safety in the adopted treatments guide the management of substance use disorders. Providers should also incorporate patients’ views into the treatment plans as a way of ensuring autonomy in the treatment process. Lisa should be educated about lifestyle and behavioral interventions that she needs to adopt to facilitate weight and blood pressure control.

References

Carmassi, C., Bertelloni, C. A., Cordone, A., Cappelli, A., Massimetti, E., Dell’Oste, V., & Dell’Osso, L. (2020). Exploring mood symptoms overlap in PTSD diagnosis: ICD-11 and DSM-5 criteria compared in a sample of subjects with Bipolar Disorder. Journal of Affective Disorders, 276, 205–211. https://doi.org/10.1016/j.jad.2020.06.056

John, W. S., Zhu, H., Mannelli, P., Schwartz, R. P., Subramaniam, G. A., & Wu, L.-T. (2018). Prevalence, patterns, and correlates of multiple substance use disorders among adult primary care patients. Drug and Alcohol Dependence, 187, 79–87. https://doi.org/10.1016/j.drugalcdep.2018.01.035

Munir, S., Takov, V., & Coletti, V. A. (2022). Generalized Anxiety Disorder (Nursing). In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK568696/

Price, M., Legrand, A. C., Brier, Z. M. F., & Hébert-Dufresne, L. (2019). The symptoms at the center: Examining the comorbidity of posttraumatic stress disorder, generalized anxiety disorder, and depression with network analysis. Journal of Psychiatric Research, 109, 52–58. https://doi.org/10.1016/j.jpsychires.2018.11.016

Proctor, S. L., Hoffmann, N. G., & Raggio, A. (2019). Prevalence of Substance Use Disorders and Psychiatric Conditions Among County Jail Inmates: Changes and Stability Over Time. Criminal Justice and Behavior, 46(1), 24–41. https://doi.org/10.1177/0093854818796062

Sliedrecht, W., de Waart, R., Witkiewitz, K., & Roozen, H. G. (2019). Alcohol use disorder relapse factors: A systematic review. Psychiatry Research, 278, 97–115. https://doi.org/10.1016/j.psychres.2019.05.038

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