Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example
Subjective: Name: Ally Patel, Gender: Female, Age: 48 years old, Race: Indian
CC (chief complaint): Come on, I miss my first lesson, and you want me to be late for the second class.
HPI: A.P is a 48-year-old Indian female who presents at the Employee Assistance Program office after a request by the concerned school principal following complaints against Ms. Ally Patel( the client) of being late for class for not less than 22 days. The patient admits she took some beer the previous night, had blacked out in a colleague’s house, and therefore had not changed dress this morning. She denies being drunk or intoxicated with alcohol reports being disrespected by some of her students and admits having separated from her husband, Ryan(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example). She also reports taking beer every night, either alone or occasionally with friends. She feels disrespected by the students who seem to have their way with teachers, are never punished, and humiliated by Mr. Michaels, the School Principal. She admits being stressed and acknowledges it contributes to her taking alcohol to take the edge off after having to deal with learners who show little if any empathy, remorse, or thoughtfulness. She reminisces there was a time she loved teaching but not anymore following her disappointment. She accepts compared to her college days, and her drinking habit has increased.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Past Psychiatric History:
· General Statement: The patient has enjoyed a relatively healthy life and reports no previous treatment related to alcohol or substance abuse.
· Caregivers (if applicable): N/A
· Hospitalizations: There are no hospital admissions the patient knows of connected to any physical or mental illness.
· Medication trials: The client has not had previous psychotropic medication prescriptions.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
· Psychotherapy or Previous Psychiatric Diagnosis: There are no previous psychotherapy or psychiatric diagnosis before referral to the EAP professional within the school who happens to be a fellow teacher.
Substance Current Use and History:
The patient admits to being introduced to alcohol during her teenage, continued with the habit in her college life, and the drinking persists well into her professional life, where she usually takes about six glasses of wine and a couple of mixed drinks. However, she denies using illicit or illegal substances, and though she admits she does not understand the mechanism, she knows alcohol affects differently than it does her friends.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Family Psychiatric/Substance Use History:
Father was an alcoholic who later joined the Alcoholics Anonymous support network and became sober. There is no other family member reported to have had a psychiatric history of issues with substance abuse.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Psychosocial History:
Born in San Francisco, CA, and raised by both parents as an only child. Before the current school year, the patient separated with Ryan, her husband, and reports seeing someone new. She has no child, graduated with a Ph.D. in biology and Masters’s in high School education grades 8-12. Micheals, her supervisor, has asked the school EAP counselor to intervene concerning her suspected alcohol abuse to facilitate her getting help and continued working within the current institution. A.P. reports no hobbies, has no history regarding any brushes with the law, and is negative for trauma history throughout her life. She has no history of violence or issues about safety.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Medical History: The patient has no history of illnesses, medical operations, and seizures.
· Current Medications: Not taking any medications prescribed or otherwise.
· Allergies:No known allergies or adverse reactions to drugs
- Reproductive Hx:Regular menstrual history and has a heterosexual sexual preference.
ROS:
· GENERAL: She is nontoxic and in no acute distress, well-appearing, oriented X3 ambulating without difficulty, and displays the normal mood and affect.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
· HEENT:
o Head Negative for visible or palpable masses, depressions, or scaring, normocephalic and with no injuries or trauma
o Eyes: visual acuity intact, EOMintact, PERRL, clear conjunctiva(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
o Ears: Hearing intact, EACs clear, T.M.s translucent and mobile
o Nose: Normal septum and turbinates, no external lesions, noninflamed mucosa
o Throat: No mucosal lesions, no thyromegaly, no voice hoarseness
· SKIN: Good turgor, no prominent lesions, no unusual bruising
· CARDIOVASCULAR: Negative for cardiomegaly or thrills, no murmur or gallop, regular rate, and rhythm
· RESPIRATORY: Clear to percussion and auscultation
· GASTROINTESTINAL: Normal bowel sounds,
no tenderness, negative for organomegaly, masses, or hernia
· GENITOURINARY: Vagina and cervix have no lesions, uterus, and parametria non-tender and without masses
· NEUROLOGICAL: CN-2-12 normal, normal sensations to pain, touch, and proprioception, no pathological reflexes, Normal DTRs in upper and lower extremities(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
· MUSCULOSKELETAL: Normal gait and station. Negative for asymmetry, crepitation, defects, tenderness, masses, or effusions
· HEMATOLOGIC: No history of unusual bleeding or easy bruising
· LYMPHATICS: No enlarged nodes
· ENDOCRINOLOGIC: Negative reports of intolerance to heat, cold or sweating, No polyuria or polydipsia
Objective:
Physical exam: if applicable N/A
Diagnostic results:
Carbohydrate –deficient transferrin (CDT) Test- CDT levels -2.7 %
Assessment:
Mental Status Examination:
Ms. Ally Patel, a 48-year-old American of Indian descent, was evaluated when she presented at the EAP office at the school. She was about 5 feet tall, wearing an executive coat and a matching skirt, but her grooming was below average. She appeared approximately her stated age and was generally cooperative throughout the session. She reported her mood as disappointed because she felt let down by the students, particularly Alexis, who dared to film her and post the video to the rest of her grade members with an obscene title. She also felt humiliated by Mr. Michales, the school principal, and thought that she works in a school with no backbone, no spine where students had their way and always escaped punishment. Her speech, when not agitated as slow, halting, and soft. (Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)During the interview, she sometimes became agitated and restless and threatened to leave. Ms. Patel described persecutory delusions where she felt the students, the parents, and the administration were not appreciating her efforts. She denied being drunk or getting intoxicated and refused to share her relationship with Ryan, mainly why she felt they had separated, citing that this was her personal life. She desired it remains that way personally. Although her perception was normal, her form of thought could best be described as circumstantial while the thought content appeared confabulated. Ms. Patel was found unreliable, exhibited poor judgment, and insight was absent considering her academic achievements before.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Differential Diagnoses:
Alcohol Abuse Disorder ICD-10 CM F10.14 Alcohol Abuse With alcohol Induced MoodDisrder – Confirmed
Medically speaking, substance abuse is described using psychological and behavioral symptoms that lead to adverse social consequences in an individual. Therefore, the EAP volunteer has to make the most appropriate diagnosis using the correct diagnostic criteria to plan treatment and monitor the client’s progress. The diagnosis of Alcohol Abuse Disorder ICD-10 CM F10.14 Alcohol Abuse With alcohol Induced MoodDisrderwas confirmed. The patient manifested a pattern of using alcohol that she had problems controlling, was preoccupied with alcohol citing it as a requirement to keep off the edge, and having to drink more to get the same desired effect (Higgins- Biddle & Babor, 2018)(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example). When she was in college, Patel had to take about six glasses of wine and a couple of mixed drinks to get the desired level of intoxication. Her binge drinking has resulted in the patient’s significant level of distress as she was currently experiencing work-related problems with the students, their parents, and her supervisor (Fuji et al., 2016).(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Furthermore, using the mnemonic DRINK TWO 6 PACK, the patient exhibited symptoms indicative of AUD. The symptoms exhibited demonstrated tolerance, withdrawal, occupational; social activities reduced six persistent desires or unsuccessful effort to cut down control on alcohol use. Amount used is excessive, continues substance use despite having recurrent physical and psychological problems, and keeps spending more time searching for, using, or recovering from alcohol (Mall, & Mall, 2009). Last but certainly not least is that diagnostic results of the CDT test indicated A.P.s level to be 2,7% indicative of chronic alcoholism(Liang et al., 2021). The DSM-5 diagnostic criteria recommend AUD if more than three of the seven symptoms are present.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
- Major Depressive Disorder DSM-5 296.20-296.36-Refuted.
Among the symptoms exhibited by Patel is loss of interest or pleasure in activities. For example, she admits she once enjoyed teaching but not anymore. She also exhibits feelings of helplessness and low self-esteem, where she reports being humiliated by her supervisor. However, diagnosis for MDD was refuted because its diagnostic criteria require a minimum of five symptoms to present like suicidal ideation, feelings of excessive guilt, difficulties sleeping or excessive sleeping, and trouble concentrating, all of which are absent in the case of Ms. Patel (Nehring et al., 2021).(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
- Generalized Anxiety Disorder DSM-5 300.02(F41.1)-Refuted
Ordinary healthy individuals may report occasional worries about money, work-related, family, or health problems but patients with GAD become extremely worried even where there is no supporting evidence(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example). According to Locke (2015), the symptoms of GAD that may overlap with those of AUD are restlessness, irritability, and edginess. As such, GAD diagnostic criteria demand that several of the symptoms listed herein be present for a minimum of six months. In addition to excessive worry, anxiety, and restlessness, the individual becomes easily fatigued, muscle tension, and the fact that the distance is not a result of the physiological effect of substance or alcohol. Subsequently, a GAD diagnosis was ruled out in the case of Ms. Patel.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Reflections:
On reflection, I would agree with my preceptor that Ms. Ally Pate is a case of AUD as outlined in the DSM-5 diagnostic criteria. However, considering the patient admits to having started alcohol use in her teenage and has continued to increase her consumption past her middle ages, I would have ordered tests like liver function. There is a need to establish the effect her drinking has on the liver and other related organs and systems. Uchtenhagen (2021) notes that the provision of treatment of AUD and other substance abuse disorders are laden with legal and ethical aspects whereby paradigm shit in the modern world considers addiction as more of a clinical / health problem as opposed to a criminal/legal problem. Additionally, people diagnosed with AUD should modify their lifestyles and learn of stress coping mechanisms. Engaging in activities and joining support groups like Alcoholic Anonymous while adhering to psychotherapy and behavioral change interventions(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
References
Fujii, H., Nishimoto, N., Yamaguchi, S., Kurai, O., Miyano, M., Ueda, W., … & Okawa, K. (2016). The Alcohol Use Disorders Identification Test for Consumption (AUDIT-C) is more useful than pre-existing laboratory tests for predicting hazardous drinking: a cross-sectional study. BMC public health, 16(1), 1-8.
Higgins-Biddle, J. C., & Babor, T. F. (2018). A review of the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, and USAUDIT for screening in the United States: Past issues and future directions. The American journal of drug and alcohol abuse, 44(6), 578-586.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Liang, S. S., He, Y., Huang, Z. G., Jia, C. Y., & Gan, W. (2021). Evaluation of the diagnostic utility of carbohydrate-deficient transferrin in chronic alcoholism: Results from Southwest China. Medicine, 100(4).
Locke, A., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American family physician, 91(9), 617-624.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Mall, S. K., & Mall, G. D. (2009). DRiNK TWO 6 PACK clarifies substance use: some patients can have substance-related adverse social consequences for a long time without developing dependence. Current Psychiatry, 8(5), 66-67.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Nehring, S. M., Freeman, A. M., & Doerr, C. (2021). Alcohol Use Disorder (Nursing).(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
Uchtenhagen, A. (2021). Ethical and Legal Aspects of Interventions in Addiction Treatment. In Textbook of Addiction Treatment (pp. 809-822). Springer, Cham.(Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Comprehensive Nursing Essay Example)
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