Comprehensive Psychiatric Evaluation

Week 9 Comprehensive Psychiatric EvaluationRachel HoraceCollege of Nursing-PMHNP, Walden University NRNP 6635:

Psychopathology and Diagnostic ReasoningDr. Justin White August 2, 2021CC

(chief complaint): My Depression and anxiety are not under control; my medication is not working(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders0. I help in changing it around.HPI: The client is a 48 years old Hispanic female who came to the office for psychiatric evaluation; she reported that she was self-referred to GC to help with her anxiety and depression. (Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

She was in the program but stopped in 2017 due to her daughter’s pregnancy and being homeless. She also reported that she has been suffering from depression and anxiety since 2004, when her first child and husband went to jail. Her husband died on August 13, 2013. She stated that her anxiety and depression had been getting worst since last year when she lost two of her aunties and her grandmother during the covid. She saw her PCP, who prescribed Ambien 5 mg and Seroquel 100mg, but she stopped taking the Seroquel to gain weight, and the anbien did not help her with her sleeplessness. The PCP also put her on Trazadone, which also was ineffective. She reported feeling hopeless and helpless, and sometimes worthless. She has low energy and a poor appetite. She denies unsafe thoughts(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Past Psychiatric History: General Statement: the client was diagnosed with postpartum depression in 2004 when she became a mother. She has been dealing with different life stressors that cause anxiety as well as depression. Caregivers (if applicable): N/A Hospitalizations: She was hospitalized in the past at Princeton house for acute depressionin Feb 2019 at an inpatient facility for seven days.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Medication trials: the client was previously prescribed Ambien 5 mg 1 tab at bedtime, Seroquel 100mg 1 tab daily, and Trazadone 50mg at HS. None of which was adequate in treating her depression and anxiety. Psychotherapy or Previous Psychiatric Diagnosis: Depression and AnxietySubstance Current Use and History: she denies substance abuse used in the past or currently.She reported that she smoked a parked cigarette in the past but quit over three years ago.Family Psychiatric/Substance Use History: Her brother was diagnosed with schizophrenia 12 years ago, no other family member is diagnosed with mental illness.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Psychosocial History: The client lives in Trenton, new jersey, with her four daughters and her grandbaby, in a four-bedroom house. He is on SSI and does not have a job due to her mental illness. Her support system is her children.Medical History: Current Medications: Allergies: KNA Reproductive Hx: client stated is is having a regular period of 3-5 days; she has notbeen sexually active since her husband passed away eight years ago (Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

ROS: GENERAL: Awake and alert HEENT: no hearing loss, no glasses, or running nose and throat discomfort SKIN: Skin is intact no bruising or marks CARDIOVASCULAR: No chest pain and discomfort, regular pulses RESPIRATORY: RRR, no coughing, LCTA GASTROINTESTINAL: No nausea, vomiting, or diarrhea; the abdomen is flat, bowel sound normal GENITOURINARY: no urinary frequency or urgency, or dysuria NEUROLOGICAL: no numbness to extremities, no facial deficit present MUSCULOSKELETAL: positive range of motion, no joint pain or discomfort (Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

HEMATOLOGIC: no bleeding disorder LYMPHATICS: lymph nodes intact non-swollen ENDOCRINOLOGIC: No history of diabeticPhysical exam: if applicable Diagnostic results: N/A AssessmentMental Status Examination: The client is awake, alert, and oriented to person, place, time, and situation. She is calm and cooperative. Appropriately dress and groomed, speech is clear, and she is coherent. Affect was normal in range, and mood is congruent. Thought progress was goal- oriented. She denies auditory, visual hallucinations, and delusion, no evidence of response to internal stimuli. She denies suicidal and homicidal ideation(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders). The ability to abstract was intact insightDifferential DiagnosisDiagnosis 1: Generalized Anxiety DisorderPathophysiology: This is a disorder that is associated with mental health. A person with this disorder is usually most of the time worried about a lot of things. One is unable to do away with these worries and anxiety. These worries may be about one’s family, health, or finances. (Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Description: Generalized Anxiety Disorder is characterized by pressing and unlimited worries. People with this mental disorder may experience a lot of problems (Gottschalk, & Domschke, 2017). This is anticipated by the fact that they are unable to overcome their worries. Explanation: Symptoms such as tensing, aches in the body, fatigue, and failure to fall asleep are some of its symptoms. During diagnoses, the doctor can conduct a physical examination or do urine or blood tests where the need arises.Diagnoses 2: Major Depression DisorderPathophysiology: One may suffer from this disorder if he or she has a prolonged period of sadness. This will tamper with the moods causing this mental disorder. As clinical depression, it can impact many parts of a person’s life.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Description: This disorder is characterized by symptoms such as feelings of restlessness, lack of energy, minimal concentration, and loss of interest in many things (Wu et al., 2019). This disorder is very common in the United States.Explanation: During diagnoses, the doctor can carry out a physical examination. For one to be diagnosed with this disorder must have had a change in functioning previously and the symptoms must have persisted for at least two weeks. Mental therapy can help in managing this disorder.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Diagnosis 3: Posttraumatic Stress DisorderPathophysiology: This is a mental disorder that is anticipated by an intimidating experience. Severe anxiety and flashbacks can also cause one to suffer from this disorder.Description: People with this disorder may have a problem with overcoming intimidating situations that they may have gone through. One experiences changes in thinking and may have negative thoughts.Explanation: Physical exam is necessary during the diagnosis of this condition. Where tests are necessary they can be done if the health practitioner recommends that. Psychotherapy is necessary for the management of this disorder (Hamblen et al., 2019).(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

References

Gottschalk, M. G., & Domschke, K. (2017). Genetics of generalized anxiety disorder and related traits. Dialogues in clinical neuroscience, 19(2), 159. https://dx.doi.org/10.31887%2FDCNS.2017.19.2%2FkdomschkeHamblen, J. L., Norman, S. B., Sonis, J. H., Phelps, A. J., Bisson, J. I., Nunes, V. D., … & Schnurr, P. P. (2019). A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update. Psychotherapy, 56(3), 359. https://psycnet.apa.org/doi/10.1037/pst0000231Wu, X., He, H., Shi, L., Xia, Y., Zuang, K., Feng, Q., … & Qiu, J. (2019). Personality traits are related with dynamic functional connectivity in major depression disorder: A resting-state analysis. Journal of affective disorders, 245, 1032-1042. https://doi.org/10.1016/j.jad.2018.11.002(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders

Introduction

Assessing and diagnosing patients are the initial steps in the psychiatric treatment continuum. Assessing patients involves evaluating the presenting symptoms, history of past illnesses, medications, and relevant social and family history to understand the patient’s condition (Dreimüller et al., 2019). This assignment presents a comprehensive psychiatric evaluation of a case scenario involving a patient with perceived substance-related and addictive disorders.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Subjective:

CC (chief complaint): “I am scared.”

HPI: LT is a 33-year-old Caucasian female. She is in Naples, Florida, at a detox facility. She is thinking about a long-term rehab for addiction and considering treatment for her Hep C+ but needs to undergo detoxification. She is worried about everything regarding rehab and wants to be persuaded to go back to rehab. She reports feeling scared. She is scared of what people will say about her going to rehab, i.e., she is an addict, and is convinced she cannot change anything about it. She reports occasionally drinking with a friend and is in control of her drinking. She does not want to be an addict. She is scared that their business with the boyfriend could be over. Nine months ago, she caught her boyfriend cheating in an office she shared with him. Worried everyone would know she was getting high and cleaned up. She believes rehabs are dirty places, yet she is such and tired of such places. She admits being broken about it and momentarily separated before the boyfriend moves back with her in her new house with her daughter. Fearful of going to rehab. “If people find out I’ve been to rehab, I won’t get a job.” She loves her boyfriend, who promised to change and introduced her to crack cocaine. At first, it “hit her like a bullet. And it felt so good. I felt so good. And real fast.” She cannot get over smoking crack cocaine and does not want to feel horrible again. She feels horrible and gets worse when she does not smoke. When she feels horrible, she knows she has to smoke again and feel good. She admits the addiction and knows she needs help but is very scared of being helped at the same time. She has a decreased appetite and prefers to get high instead of eating.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Past Psychiatric History: None reported.

Hospitalizations: None reported.

Medication trials: None reported.

Psychotherapy or Previous Psychiatric Diagnosis: None reported.

Psychosocial History:

Substance Current Use and History: She abuses opiates for approximately $100 daily. She admits to cannabis 1–2 times weekly (“I have a medical card”) and more than five shots of vodka daily.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Family Psychiatric/Substance Use History: Older brother has a history of opioid use. Mother has a history of agoraphobia and benzodiazepine abuse.

Social History:

Home Environment: Lives with the boyfriend. Has a daughter. She is estranged from her father. The mother lives in Maine. The older brother has not contacted with family in the last ten years.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Educational Level: Not reported.

Hobbies: Not reported.

Occupation: Does commercial for local businesses.

Legal history: She has a past drug paraphernalia possession arrest.

Lifestyle: Sleeps 5-6 hrs.

Medical History:

Current Medications: None reported.

Allergies: Azithromycin.

Reproductive Hx: Sexually active. Regular menstruation.

ROS

GENERAL: No fatigue, fever, or chills. No weight gain, loss, or body aches.

HEENT:

Head: No headache.

Eyes: No diplopia or blurred vision.

Ears/Nose/Throat: No ear pain or loss of hearing. No nasal congestion. No sore throat.

ENDOCRINOLOGIC: Decreased appetite. No heat/cold intolerance. CARDIOVASCULAR: No chest pain, dizziness, or short breath. GASTROINTESTINAL: No abdominal pain or constipation.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

GENITOURINARY: No vaginal discharge or urinary hesitance. No polyuria or dysuria.

LYMPHATICS: No swollen lymph nodes.

INTEGUMENTARY: Intact skin.

NEUROLOGICAL: No weakness, tremor, or numbness.

MUSCULOSKELETAL: No joint or muscle pain.

PSYCHOLOGICAL: Anxiety.

RESPIRATORY: No cough, wheeze, or sputum.

Objective:

Vital Signs: T- 100.0, P- 108, R 20, BP 180/110, Ht 5’6 Wt, 146lbs, BMI = 23.6 kg/m²  (Normal weight).

Physical exam: LT is a 33-year-old, well-developed, and looks the stated age. Vital signs are the measurements. Skin is moist with normal turgor. Steady gait.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Diagnostic results:

ALT 168.

AST: 200.

ALK: 250

Bilirubin: 2.5

Albumin: 3.0

GGT: 59

UDS: Positive for opiates.

THC. Positive for alcohol or other drugs.

BAL: 308.

Assessment:

Mental Status Examination: Appears disoriented. Inappropriately groomed. In acute psychological distress. Agitated but interactive. Maintains fair eye contact. Affect congruent with a stated mood of feeling scared. Expansive emotional range. Resigned thought-form and content. Had some attentional and concentration problems during the exam. Poor insight. Normal cognition, but difficulty with abstraction. Poor judgment. No past or current suicide or homicide ideation. The patient is at low risk of self-harm or harm to others.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Differential Diagnoses:

1. Moderate Stimulant (Cocaine) Use Disorder (SUD), 20 (F14.20). The essential features of cocaine use disorder presented by this patient include clinically significant distress, large consumption over an extended period, persistent desire to cut down use, craving, recurrent stimulant use, tolerance, and withdrawal (American Psychiatric Association [APA], 2019). These symptoms tend to occur within 12 months. Usually, individuals know the effect of the problematic stimulant use but cannot reduce its use or cease using such substances. In this case, the client has problematic crack cocaine use, admitting that she cannot get enough or over smoking crack cocaine. For her, smoking crack feels so good and real fast. She feels horrible when she does not smoke crack and knows it is time to smoke again and feel good. Significantly, she has a decreased appetite, and rather than eating, and she prefers to get high.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)
2. Moderate alcohol use disorder (AUD), 90 (FI 0.20). The essential diagnostic features for a moderate AUD include alcohol use pattern leading to significant distress characterized by larger amounts of alcohol consumption, persistent desire to cut down alcohol use, much time spent in obtaining, using, or revering from the effects of alcohol use, craving, recurrent use affecting normal routines, impaired social activities, recurrent use, tolerance, withdrawal, and continued use despite the knowledge of its effects (APA, 2019). These symptoms tend to occur within 12 months. The client admits taking more than 5 shots of vodka daily, which she says she has control over, is a significant amount of daily alcohol intake. Besides, the client’s diagnostics test results are positive for alcohol.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)
3. Opioid Withdrawal, 292.0 (F11.23). The essential features of opioid withdrawal include reduction of heavy and prolonged opioid use, administration of opioid antagonists resulting in either vomiting, diarrhea, muscle aches, dysphoric mood, fever, insomnia, rhinorrhoea, sweating, or Pupillary, and clinically significant impairment. These symptoms must not be attributed to other medical illnesses or substances. The client’s diagnostic results (USD) are positive for opiates, and the subjective data shows that she has been abusing opiates, approximately $100 daily.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Reflections

Moderate stimulant use disorder with cocaine is the primary diagnosis in the case. The client presents the primary characteristic of SUD, which is the instant confidence, euphoria, and feeling of well-being after taking cocaine (APA, 2019). The alcohol use disorder and opioid withdrawal diagnoses are equally symptomized by the patient considering the heavy daily alcohol intake and positive opioid diagnostic tests. However, the significant problem the client has for which she has no control, as evidenced by the HPI, is another subjective data, cocaine use.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Addictions are typically associated with risk factors, interactions, and external influences. In this case, the client’s cocaine use is driven by previous negative life experiences and the need to relieve the negative life experiences. For instance, she admits feeling good after smoking crack cocaine and knows she has to smoke again when she feels horrible. Her negative life experiences include the loss of business finance and having caught her boyfriend cheating on her in an office room they share for their business. Besides the rewarding feeling associated with cocaine use, women tend to abuse cocaine due to dissociative experiences and the need to relieve negative life experiences (Tractenberg et al., 2022).(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Working with patients having substance uses illnesses requires significant consideration of various ethical issues. Central to working with addicted patients are the ethical issues related to informed consent. Usually, clinicians need to obtain written and spoken consent from the client to proceed with any form of intervention, including psychiatric evaluation (Jonnalagadda, 2021). Patients have the right to accept or refuse treatment, including the assessment methods they are subjected. Obtaining informed consent should also be accompanied by the complete disclosure of the relevant information relating to the procedures or approach the clinician intends to follow when handling a patient. This help prevents own biases and reactions to clinical situations and avoids unethical behavior.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Furthermore, confidentiality issues, i.e., reporting and keeping patient reports, are critical considerations when dealing with addicted patients. In this case, the client is concerned that she may not get a job when people find out she is an addict and what people will say when they learn that she is in rehab. Considering the multidisciplinary nature of mental health management, health personnel should be aware of confidentiality issues when sharing information with other health team members, and all information about the patient should be objective, neutral, and cognizant of professional limitations (Jonnalagadda, 2021). Moreover, healthcare personnel should provide the patient with information in an appropriate language depending on the patient’s understanding. Significantly, reporting mechanisms should maintain the patient’s dignity and autonomy, which are equally essential ethical practices considering the vulnerability of mental health patients, sensitivity of substance use addiction, and impact of the in-patient treatment environment on patients.

Besides the ethical considerations, there is a need to recognize that cocaine addiction is a complex condition that affects the brain and interpretation of various environmental, social, and familial issues (National Institute on Drug Abuse [NIDA], 2020). As such, psychiatric assessment must address cocaine addiction in a broader context, i.e., evaluating causal factors, stimuli, and co-occurring conditions to guide pharmacological and behavioral interventions.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Conclusion

The patient’s symptoms are characteristic of substance use disorder. Per the HPI and the diagnostic results, the patient has a cocaine addiction, characterized by heavy smoking, desire to quit smoking, craving, more time spent smoking, and distress. The symptoms present for about nine months, and the client’s environment is the primary influence(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders). Moreover, the client presents alcohol use disorder and opioid withdrawal, which have not been refuted but have a lower rank in terms of significance. In this case, the intervention should consider managing all the presented diagnoses as they co-occur. Furthermore, the psychiatrist should consider various ethical issues when dealing with the patient, including informed consent, confidentiality, and autonomy. Therefore, psychologists should always serve the interest of the patients using the best available evidence for psychiatric evaluation and uphold the ethical principles as outlined by existing regulatory bodies.(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders  (7^th ed.). American Psychiatric Publishing, Inc.   (Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Dreimüller, N., Schenkel, S., Stoll, M., Koch, C., Lieb, K., & Juenger, J. (2019). Development of a checklist for evaluating psychiatric reports. BMC medical education, 19(1), 1-9. https://doi.org/10.1186/s12909-019-1559-1(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Jonnalagadda, V. R. (2021). Ethical Considerations in Substance Use Disorders Treatment. Psychiatric Clinics, 44(4), 579-589. https://doi.org/10.1016/j.psc.2021.08.009(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

Tractenberg, S. G., Schneider, J. A., De Mattos, B. P., Bicca, C. H., Kluwe-Schiavon, B., de Castro, T. G., … & Grassi-Oliveira, R. (2022). The Perceptions of Women About Their High Experience of Using Crack Cocaine. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.898570(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)

National Institute on Drug Abuse (NIDA). June 2020. How is cocaine addiction treated? Retrieved from https://nida.nih.gov/publications/research-reports/cocaine/what-treatments-are-effective-cocaine-abusers (Accessed 5 July 2022)(Comprehensive Essay on Assessing and Diagnosing Patients with Substance-Related and Addicted Disorders)