Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders

Substance use and addictive disorders are some of the challenging health concerns on a global scale. They are a reason for suffering, incarcerations, morbidity, and mortality. Some of the most commonly abused substances include alcohol and opioid medications, among other illicit substances. Addiction is the most severe form of substance disorder. This paper reviews a case involving substance-related and addictive disorders.

Subjective:

CC (chief complaint): “I am feeling scared.”

HPI: A 33-year-old female presents to the clinic for assessment and subsequent admission into long-term rehab but is scared. The patient is scared of going into rehabilitation for her drug use problems. The problem started after she found out that her boyfriend was cheating on her. She has since been taking crack with her boyfriend. The patient notes that she cannot get enough of the crack. She feels horrible when she doesn’t smoke and good when she smokes the crack, making her want to get another crack. The patient knows she needs some help but is scared of getting help. The drug use problem has brought the patient and her boyfriend into financial losses amounting to over 80,000 dollars.

Past Psychiatric History:

• General Statement: The patient has hepatitis C. No reports of past psychiatric illnesses.
• Hospitalizations: Denies any past hospitalizations
• Medication trials: No past medical trials
• Psychotherapy or Previous Psychiatric Diagnosis: The patient was sexually abused by the father between the ages six and nine.

Substance Current Use and History: The patient has been abusing opiates at an approximate cost of one hundred dollars per day; she also used cannabis 1-2 times a week and a half a gallon of vodka daily.

Family Psychiatric/Substance Use History: Mother has agoraphobia and benzodiazepine abuse. The father was imprisoned for sexually abusing her. Her brother has a history of opioid use.

Psychosocial History: The patient currently lives with her boyfriend. She was estranged from her brother for ten years.

Other: The patient sleeps for 5-6 hours a day. She has a decreased appetite and prefers to get high rather than eat. She has a history of arrest for possession of drug paraphernalia.

Medical History:

• Current Medications: None.
• Allergies: Azithromycin

ROS:

• GENERAL: No reports of weight gain or weight gain.
• HEENT:  Denies visual loss, nasal discharge, or difficulty swallowing.
• SKIN: Denies skin lesions.
• CARDIOVASCULAR: Heart rate is elevated.
• RESPIRATORY: No reports of wheezing or shortness of breath.
• GASTROINTESTINAL: No reports of bowel movement inconsistencies.
• NEUROLOGICAL: denies depression or anxiety.
• MUSCULOSKELETAL: Denies muscle pain or joint swelling.
• LYMPHATICS: No reports of lymph node swelling.
• ENDOCRINOLOGIC: No reports of heat or cold intolerance.

Objective:

Vital signs: T- 100.0 P- 108 R 20 180/110 Ht 5’6 Wt 146lbs

Physical exam:  

Cardiovascular exam: Cardiovascular examination is warranted in patients with substance use disorders to rule out cardiovascular complications of drug use. Long-term and excessive use of alcohol and other substances of abuse causes arterial stiffening and myocardium thickening, with resultant elevation in blood pressure (Chelikam et al., 2022).

Abdominal exam: Long-term use of alcohol and other substances of abuse have untoward effects on the liver. Abdominal examination in persons with a significant history of substance use can help rule out liver tenderness as a consequence of substance (Haque et al., 2020).

Diagnostic results:  ALK 250, bilirubin 2.5, ALT 168, Albumin 3.0, GGT 59; AST 200, Urinary drug screening positive for opiates. She is also positive for THC and alcohol. Her blood alcohol level is 308.

Assessment:

Mental Status Examination: The patient is alert and responsive. She is also oriented to places and events. She seems disorganized and illogical in her thought process. Her memory and judgment are intact, and her mood is sad.

Differential Diagnoses: 

Substance use disorder (SUD) ICD-10 Code F19.99:  The patient in the case presented had a compulsion to take alcohol and opiates. She noted that he was unable to stop despite wanting to. Likewise, her drug use resulted in significant social impairments, as demonstrated by her losing money. This warranted this diagnosis.

Opioid Use Disorder ICD-10 Code F11.19: Opioid use disorder is a condition of chronic use of opioids causing significant impairment (Herscher et al., 2020). The patient in the case presented was unable to stop taking opioids and craved opioids. Likewise, the opioid use resulted in significant financial losses and impairments in her social life, warranting the inclusion of this differential.

Ethanol toxicity ICD-10 Code T51.0X1A: Ethanol toxicity is a life-threatening condition resulting from excessive consumption of alcohol (Mirijello et al., 2023). The presence of cardiovascular symptoms such as elevated pulse rates and blood pressure, coupled with an extensive history of alcohol consumption and diagnostic findings of a blood alcohol level of 308, warranted the inclusion of this differential.

Diagnosis: The presumptive diagnosis is substance use disorder (SUD) ICD-10 Code F19.99. SUD is a psychiatric condition characterized by compulsive drug-seeking behavior and persistent use of drugs despite their consequences (Pasha et al., 2020). A positive in this case is the presence of significant history of substance use, coupled with impulsion to take substance of abuse, warrants this diagnosis (DSM-V, n.d).

Reflections:

The interview captured many assessment aspects of substance use disorder.  An ethical consideration for the client is beneficence. The patient is at high risk of injury due to her impaired mentation, deteriorating health condition, and addiction. Beneficence implores the caregivers to act in the best interest of the patient. This includes guiding her into making decisions that will enhance her chances of wellness. Access to care is a social determinant of health that applies to the case. Caregivers can ensure the patient access to high-quality psychiatric care by recommending a rehabilitation center that is acceptable to her and applicable to the case.  As a point of health promotion for the patient, she should be educated on the benefits of rehabilitation in ensuring her wellness.

Conclusion

Substance use disorders are a health concern. The case study typifies the health impacts of substance abuse and the role of caregivers in managing patients with substance use disorders. The patient in the case could benefit from rehabilitation.

References

Chelikam, N., Vyas, V., Dondapati, L., Iskander, B., Patel, G., Jain, S., Singla, T., Bombaywala, A., Zarrate, D., Debnath, N., Jain, N. K., Peela, A. S., Patel, U. K., & Sharma, A. (2022). Epidemiology, burden, and association of substance abuse amongst patients with cardiovascular disorders: National cross-sectional survey study. Cureus. https://doi.org/10.7759/cureus.27016

DSM-V. (n.d.). DSM. Psychiatry.org – DSM. https://www.psychiatry.org/psychiatrists/practice/dsm

Haque, L. Y., Jakab, S., Deng, Y., Ciarleglio, M. M., & Tetrault, J. M. (2020). Substance use disorders in recently hospitalized patients with cirrhosis. Journal of Addiction Medicine, 14(6). https://doi.org/10.1097/adm.0000000000000677

Herscher, M., Fine, M., Navalurkar, R., Hirt, L., & Wang, L. (2020). Diagnosis and management of opioid use disorder in hospitalized patients. Medical Clinics of North America, 104(4), 695–708. https://doi.org/10.1016/j.mcna.2020.03.003

Mirijello, A., Sestito, L., Antonelli, M., Gasbarrini, A., & Addolorato, G. (2023). Identification and management of acute alcohol intoxication. European Journal of Internal Medicine, 108, 1–8. https://doi.org/10.1016/j.ejim.2022.08.013

Pasha, A. K., Chowdhury, A., Sadiq, S., Fairbanks, J., & Sinha, S. (2020). Substance use disorders: Diagnosis and management for Hospitalists. Journal of Community Hospital Internal Medicine Perspectives, 10(2), 117–126. https://doi.org/10.1080/20009666.2020.1742495

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An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.

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.

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.
  

  Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders

By Day 7 of Week 8
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.).
• submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

To submit your completed assignment, save your Assignment as WK8Assgn_LastName_Firstinitial
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select Submit Assignment for review.

Resources:

• DSM-5-TR  text
• Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). WoltersKluwer.
• Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.