ASSIGNMENTS Week 8

ASSESSING AND DIAGNOSING PATIENTS WITH SUBSTANCE-RELATED AND ADDICTIVE DISORDERS

For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background.

RESOURCES

• American Psychiatric Association. (2022). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?u… https://dsm.psychiatryonline.org/doi/full/10.1176/…
  • Chapter 4, “Substance Use and Addictive Disorders”
  • Chapter 2 only section 2.17, “Adolescent Substance Abuse”
  • Chapter 27 “Ethics and Professionalism”
  • Chapter 28 “Forensic and Legal Issues”

Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

TO PREPARE:

• Review this week’s Learning Resources and consider the insights they provide.
• Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
• By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
• Identify at least three possible differential diagnoses for the patient.

Selected Video case for the assignment

Symptom Media. (Producer). (2017). Training title 82Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-82

Case History Report

Training Title 82
Name: Lisa Tremblay
Gender: female
Age: 33 years old
T- 100.0 P- 108 R 20 180/110 Ht 5’6 Wt 146lbs
Background: Lisa is in a Naples, FL detox facility thinking about long term rehab. She is
considering treatment for her Hep C+ but needs to get clean first. She has been abusing opiates,
approximately $100 daily. She admits to cannabis 1–2 times weekly (“I have a medical card”),
and 1/2 gallon of vodka daily. She has past drug paraphernalia possession arrest. Her admission
labs. abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS
positive for opiates, THC. Positive for alcohol or other drugs. BAL .308; other labs within
normal ranges. She reports sexual abuse as child ages 6-9 perpetrator being her father who went
to prison for the abuse and drug charges. She is estranged from him. Mother lives in Maine, hx
of agoraphobia and benzodiazepine abuse. Older brother has not contact with family in last 10
years, hx of opioid use. Sleeps 5-6 hrs., appetite decreased, prefers to get high instead of eating.
Allergies: azithromycin
Symptom Media. (Producer). (2017). Training title 82 [Video].
https://go.openathens.net/redirector/waldenu.edu?u…
tch/training-title-82

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment? 
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest 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.
• Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.).

Assignment_Rubric

Criteria

Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. In the Subjective section, provide: • 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

Ans:

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

Criteria

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.

Ans;

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

Criteria

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.

Ans;

The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

Criteria

Reflect on this case. 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.).

Ans;

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Criteria

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

Ans;

The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.

Criteria

Written Expression and Formatting—Paragraph development and organization:Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

Ans;

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. …Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

Criteria

Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation

Ans;

Uses correct grammar, spelling, and punctuation with no errors