Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example

Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example

Patient Initials: D.P.

Gender: Female

SUBJECTIVE:

CC: “I have continuous elbow pain and freaquent headaches, and no medication would work for me except oxycodone that I asked the family physician to prescribe for me. I need a prescription that will help me doc.”

HPI: The patient is a 47-year-old White female who presents to the hospital with chronic elbow pain and frequent headaches. The patient reports that he asked the family physician to prescribe oxycodone for her elbow pain because no other medications or non-pharmacological interventions would help her. She reports that ibuprofen, acetaminophen, and morphine do not help with her pain, and she is allergic to codeine and Tylenol 3. The patient admits morphine is addictive, and Dialudid made her dizzy and constipated when she tried, almost getting hospitalized. She also tried Demorol, which only helped with her headache. The patient reports using yoga for her pain, but ineffective when she stops, and warm, hot compresses, candles, long walk on the beach, and massages. D.P. reports taking vitamins like fish oils. She reports only taking medications for her headache and elbow pain but also admits using other substances and drugs, including alcohol on special occasions, marijuana, which helps with her headaches, cocaine, to relieve tension, ecstasy, LSD, caffeine, cigarettes, Ritalin, Dexedrine, and uses Klonopin, Ativan, Xanax for her anxiety and when her meditation is not working. The patient reports sleeping an average of 5-6 hours and has a good appetite.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Social History: D.P. moved from Russia to Washington with her parents when she was 16. She has a younger brother and three older sisters. She currently lives with her boyfriend in Boise, Idaho. The patient has a son, Casper, who lives with her ex’s parents. She lost custody of her son for being perceived unsuitable after she was caught using cocaine. Her boyfriend has two children, who also live with his ex, and they are not allowed to see them.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Education and Occupation History: Patient dropped out of highschool in 10^th grade. She currently works as a part time cashier at Save A Lot Grocery Store.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Substance Current Use and History: D.P. reports a history of substance and alcohol use

• Alcohol, once or twice a week, gets intoxicated sometimes when drinking with her boyfriend.
• Marijuana, 2-4 times a week, admits to growing marijuana before moving to the current state.
• Cocaine, one or two months ago.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)
• Ecstasy, twice
• LSD, once last year
• Caffeine, a lot daily
• Cigarettes, two packs a day
• Ritalin
• Dexedrine
• Klonopin, Ativan, Xanax, two times 

Legal History:

            Charged for drinking and driving

            Her boyfriend was caught seeling marijuana

Family Psychiatric/Substance Use History: Denied family mental health or substance use issues.

Past Psychiatric History:

            Hospitalization: Denies history of inpatient detox or rehab

Medication trials: No previous medical trails

Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnosis

Medical History: Patient has fibromyalgia.  

• Current Medications: Patient reports taking Ritalin, Dexedrine, and uses Klonopin, Ativan, Xanax for her anxiety and when her meditation is not working. Patient admits taking oxycode for her elbow pain, initially prescribed for her boyfriend(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)
• Allergies: Patient is allergic to codeine
• Reproductive Hx: Sexually active. Patient uses condoms for birth control. Patient reports regular menses.

ROS:  

General: Denies weight loss or gain, fever, chills, weakness, or fatigue.

HEENT: Eyes: Patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. The patient reports good appetite.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color

Neurological: Patient reports frequent headaches, denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Denies concentrating and attention problems. Patient reports memery problems she was born with. (Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Musculoskeletal: Denies muscle, back pain, or stiffness. Patient reports chronic elbow pain.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Denies sweating. No reports of cold or heat intolerance. No polyuria or polydipsia.

OBJECTIVE:

Vital signs: Stable

Temp: 98.8F

            B.P.: 132/90

            P: 84

             R.R.: 20

             O2: Room air

             Pain: 7/10

             Ht: 5’8 feet

             Wt: 128 lbs

             BMI: 19.5

             BMI Range: Healthy weight

LABS:

Lab findings WNL

Tox screen: Positive

Alcohol: Positive

Physical Exam:

General appearance: The patient appears healthy and well-fed, with the BMI indicating healthy weight. The patient converses appropriately and regularly with the interviewer. The patient was cooperative and answered the questions appropriately and comprehensively.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Cardiovascular: The patient’s heartbeat and rhythm are regular. The patient’s heart rate is constant, and capillaries refill in two seconds.  (Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Musculoskeletal: Normal range of motion. Low muscle mass for age. No signs of swelling or joint deformities. Patient reacts to elbow movements. Rated elbow pain 7/10 on the pain scale.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear. Patient has frequent headaches and reports memory problems.

Psychiatric: The patient is attentive and cooperative.

Neuropsychological testing: Social-emotional functioning is normal.

Behavior/motor activity: Patient behavior was appropriate and constant throughout the assessment

Gait/station: Stable.

Mood: The patient exhibited an “okay” mood.

Affect: The patient’s mood was “okay.”

Thought process/associations: comparatively linear and goal-directed.

Thought content: Thought content was appropriate.

Attitude: The patient was cooperative throughout the assessment

Orientation: Oriented to self, place, situation, and general timeframe.

Attention/concentration: Good

Insight: Good

Judgment: Good.

Remote memory: considered good

Short-term memory: considered good

Intellectual /cognitive function: considered good

Language: clear speech, with a tone, assessed to be normal

Fund of knowledge: Good.

Suicidal ideation: The patient denies any suicidal ideation and is negative for active plans or intent.

Homicide ideation: Negative.

ASSESSMENT:

Mental Status Examination:

The patient is a 47-year-old White female presenting at the clinic with chronic elbow pain and frequent headaches. She needs an oxycodone prescription because no other medication works for her. Patient behavior was appropriate and constant throughout the assessment. The patient had a stable gait and exhibited an “okay” mood. The patient was involved during the interview. The patient’s affect was “okay”. The thought process is comparatively linear and goal-directed. The patient thought the content was appropriate. The patient’s attitude was cooperative throughout the assessment. She is oriented to self, place, situation, and general timeframe. Attention and concentration are good, insight is good, judgment is good, remote memory good, and short-term memory is good. Her intellectual and cognitive function was good, her fund of knowledge is good, and her language and speech were clear, with a normal tone. The patient denies any suicidal ideation and is negative for active plans or intent and homicide ideation.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Differential Diagnosis:

1. F19. 10 Substance Use Disorder:

Individuals develop substance use disorder from extended exposure to substances and resultant mental and physical dependence. Substance use disorder is linked to social, academic, and occupational problems (Jahan & Burgess, 2021). The DSM-5 criteria are adopted in establishing substance use disorder diagnosis. The patient must meet a minimum of two of the 11 criteria over 12 months for the diagnosis to be confirmed. Per the DMS-5, the substance must have been used excessively and longer than intended, the patient tried but failed to decrease use, the patient uses extra time and effort to obtain the substance or recover after use, the patient reports excessive craving for the substance, substance use affects responsibility fulfillment, continued use despite social and occupational problems after use, continued use replaces other activities, substance use when driving or other high-risk settings, continued use despite knowledge of harmful psychosocial and physical effects, the patient has developed tolerance, and patient reports withdrawal symptoms (Jahan & Burgess, 2021). The patient, in this case, reports using alcohol despite negative effects like legal problems. The patient also reports drinking while driving, and she has tried but failed to cut back on her daily cigarette consumption of two packs. The patient lost custody of her son due to cocaine use. The patient also reports getting intoxicated when drinking with her boyfriend. Per the DMS-5 criteria, the patient meets at least two of the 11; hence the diagnosis was confirmed.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

• F41.9 Anxiety

Anxiety, a closely linked emotion to fear, takes the form of a future-oriented emotional state that includes a cognitively demanding, affective, physiological, and behavioral reaction system built to prepare for impending events or circumstances viewed as harmful. Patients describe feeling nervous, restless, or tense and sensing impending danger (Chand & Marwaha, 2022). Physical symptoms include trouble focusing, rapid breathing, shivering, shaking, and sweating. Per the DMS-5, the patient must indicate excessive anxiety and worry, occurring for at least six months, about different things. The patient should also report difficulties controlling worry. In this case, the patient reports using marijuana and other drugs to control anxiety. However, she does not indicate excessive apprehensive expectations, making the diagnosis unlikely.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

• 296.2. F32.9 Major Depressive Disorder

Depression can co-occur with substance use disorder. It can be exhibited in alcohol, sedatives, cannabis, anxiolytics, opioids, and hypnotics. Depression is also linked with stimulant withdrawal. Depression is a mood disorder leading to constant sorrow and disinterest. The characteristics of melancholy, emptiness, or irritability are present in all depressive disorders, as well as physical and cognitive alterations that substantially impact the patient’s ability to function (Chand et al., 2021). For the majority of the day, practically every day, patients who are depressed often have a markedly diminished interest in or enthusiasm for almost all activities. Per the DMS-5 criteria, 5 of the following symptoms must exist to make a diagnosis: sleep difficulties, interest or pleasure reduction, thoughts of worthlessness and guilty feeling, fatigue and energy fluctuations, problems concentrating or paying attention, weight and appetite changes, psychomotor issues, suicidal thoughts, and depressed mood. This diagnosis cannot be made because the patient does not meet 5 of the 9 symptoms listed above, reporting sleeping disturbance as the primary symptom associated with depression. (Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

PLAN:

The patient would benefit from a combination of medication and non-pharmacological interventions. .

Safety Risk/Plan:

The patient indicates no intent to cause self harm or harm to others. Patient has no suicidal or homicidal ideation. No admissions are required.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Treatment and Management:

The patient needs assistance to begin the recovery process in a structural and supportive environment.

Pharmacologic  Interventions:

Bupropion and varenicline will treat excessive nicotine use. Bupropion is a dopamine and norepinephrine reuptake inhibitor, helping reduce nicotine cravings and withdrawal symptoms. Varenicline is a partial agonist that will help treat withdrawal symptoms (Jahan & Burgess, 2021). Acamprosate and naltrexone will be prescribed to treat alcohol use. Disulfiram will make alcohol consumption unpleasant by producing headaches, nausea, flushing, dizziness, weakness, and vomiting (Jahan & Burgess, 2021). Naltrexone will reduce cravings and help prevent alcohol use relapse.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)  

Psychotherapy:

Nicotine replacement therapy is recommended to treat nicotine dependence and guide the patient towards smoking cessation. Contingency management that uses operant conditioning reinforcement will help with stimulant dependence, including cocaine. It helps patients change unpleasant behaviors through behavioral rewards (Jahan & Burgess, 2021). The behavior is modified by rewarding the patient when they fulfil the desired bevehavior, reducing substance use and enhancing abstinence in the process.  (Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Education:

1. Offer education and resources for smoking cessation
2. Educate the patient regarding toxicity, side effects, potential complications, and need for medication adherence.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)
3. Monitor for side effects and withdrawal signs.
4. Educate the patient regarding making healthy lifestyle choices.
5. Encourage the patient to work with the healthcare team and seek help anytime.  
6. Advise the patient to join a support group or group therapy to help with substance use disorder.

Consultation/follow-up: Follow-up is in one week for further assessment.  

Referral: The patient needs to see a primary physician to begin treatment of fibromyalgia

Reflection

Most people do not realize or admit to substance use disorder because it is considered normal human behavior, especially when the frequency is not as much. Without professional intervention, substance use disorder can go undiagnosed throughout a lifetime because patients do not understand when symptoms are clinically significant. In this case, the patient reports to the clinic with a chief complaint of elbow pain and headaches, requesting an oxycodone prescription to manage her elbow pain. However, during the assessment, the interviewer discovers that the patient is using multiple drugs for different reasons, and no medical drugs she uses are prescribed to her by a professional. (Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)The patient downplays using some drugs and justifies using others. She is not overly concerned with her drug use, although clinically, she exhibits symptoms and signs of substance use disorder. Such cases make substance use disorder one of the most underdiagnosed, underreported, and undertreated disorders. After this realization, the physician has to ascertain that the patient has sound decision-making capacity and can be trusted with the provided information, which raises ethical issues of patient autonomy. Often, a practitioner might inquire from a third party for comprehensive assessment, which makes a patient perceive a threat to their autonomy. It can also be challenging to minimize harm while maintaining patient autonomy when levels of capacity to make decisions fluctuate. In another meeting with the patient, I would inquire more about her boyfriend. It appears she drinks a lot around him, and most of the drugs she has tried it was with him. The boyfriend significantly influences the patient’s substance and alcohol use, and I would request his presence in the next meeting.  (Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

References

Chand, S. P., & Marwaha, R. (2022). Anxiety. In: StatPearls [Internet]. StatPearls Publishing.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing). In: StatPearls [Internet]. StatPearls Publishing.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

Jahan, A. R., & Burgess, D. M. (2021). Substance Use Disorder. In: StatPearls [Internet]. StatPearls Publishing.(Comprehensive Psychiatric Evaluation of a Substance Use Disorder and Other Addictive Disorders-Nursing Paper Example)

https://www.ncbi.nlm.nih.gov/