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Topic:

Substance-Related and Addictive Disorders

Essay Instructions:

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.
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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.).
Learning Resources
Required Readings (click to expand/reduce)
American Psychiatric Association. (2013). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm16
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
Chapter 20, Substance Use and Addictive Disorders
Chapter 31.16, Adolescent Substance Abuse
Case Scenerio:
Training Title 82
Name: Lisa Pittman
Gender: female
Age: 29 years old
T- 99.8 P- 101 R 20 178/94 Ht 5’6 Wt 140lbs
Background: Lisa is in a West Palm Beach, FL detox facility thinking about long term rehab. She
has been smoking crack cocaine, approximately $100 daily. She admits to cannabis 1–2 times
weekly (“I have a medical card”), and 2–3 alcohol drinks once weekly. She has past drug
possession and theft convictions; currently on 2 yr probation with randomized drug screens.
She tries to find the pattern for the calls in order not to test dirty urine. Her admission labs
abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS positive
for cocaine, THC. Negative for alcohol or other drugs. BAL 0; other labs within normal ranges.
She reports sexual abuse as child ages 5–7, perpetrator being her father who went to prison for
the abuse and drug charges. She is estranged from him. Mother lives in Alabama, hx of anxiety,
benzodiazepine use. Older brother has not contact with family in last 10 years, hx of opioid use.
Sleeps 4-5 hrs, appetite decreased, prefers to get high instead of eating. Allergies: amoxicillin
She is considering treatment for her Hep C+ but needs to get clean first.
Symptom Media. (Producer). (2017). Training title 82 [Video]. https://video-alexanderstreetcom(dot)ezp(dot)waldenulibrary(dot)org/watch/training-title-82

Essay Sample Content Preview:

Week 8: Substance-Related and addictive disorder
Subjective:
CC (chief complaint): "Yes, alcohol affects. Yes."
HPI: TL is a 30 years old Caucasian single female teaching at a school. The patient has reported that she feels that alcohol use affects her differently. It has impacted her relationships and her work too. The patient admits that she drinks more often than in the past and attributes the stress to school issues such as difficult students and lack of support. The patient reports that some of the students are disrespectful. She provides an example of a student taking a picture of her and then sharing it with classmates while using an abusive title. She feels that teaching has lost meaning, and as a result, she has begun drinking frequently. She drinks every night of the week, and she also adds that she feels "lucky" if she fails to pass out due to heavy drinking. On admission, the patient was positive for alcohol abuse.
Past Psychiatric History:
* General Statement: N/A
* Caregivers (if applicable): N/A
* Hospitalizations: N/A
* Medication trials: N/A
* Psychotherapy or Previous Psychiatric Diagnosis: N/A
Substance Current Use and History: The patient drinks every night.
Family Psychiatric/Substance Use History: The patient's father was an alcoholic.
Psychosocial History: The patient is single and lives alone. She was raised by both parents and is working as a teacher. She does not have any hobbies, and most times, she is attending parties.
Medical History:
* Current Medications: N/A
* Allergies: N/A
* Reproductive Hx: N/A
ROS:
* GENERAL: No fatigue, weaknesses, chills, fever, or weight loss.
* HEENT: Eyes: No yellow sclerae, double vision, blurred vision, or visual loss. Ears, Nose, Throat: No runny nose, sore throat, sneezing, hearing loss, or congestion.
* SKIN: patient reports no itching or rashes.
* CARDIOVASCULAR: The patient does not feel any chest discomfort, chest pressure, and chest pain. Patient negative for edema or palpitations.
* RESPIRATORY: The patient does not have any sputum, cough, or shortness of breath.
* GASTROINTESTINAL: No numbness, ataxia, paralysis, syncope, dizziness, or headache.
* GENITOURINARY: No odd color, odor, urgency, hesitancy, or burning on urination.
* NEUROLOGICAL: No numbness, dizziness, syncope, ataxia, headache, tingling in extremities, or paralysis. The patient reports no change in bladder or bowel control
* MUSCULOSKELETAL: No stiffness, joint pain, back pain, or muscle pain.
* HEMATOLOGIC: No bruising, bleeding, or anemia.
* LYMPHATICS: Nodes are normal and have not undergone splenectomy.
* ENDOCRINOLOGIC: The patient has no polydipsia or polyuria. No heat intolerance, cold, and sweating.
Objective:
Physical exam: VS: T-99.8, P-101, R-20, BP -179/94. Ht -5’6, Wt -150lbs. The patient presents as tired, weary, and is depressed.
Diagnostic results: Positive for alcohol.
Assessment:
Mental Status Examination: The patient is alert and oriented to time, place, and location. Her hair is unkempt, and a scent of alcohol is coming out of her mouth. Her speech is coherent and clear. She was not cooperative at first and appears tired and sleepy. She does not have any suic...
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