Assessing And Diagnosing Patients With Substance-Related And Abuse Disorders Soap Note

Assessing and Diagnosing Patients with Substance-Related and Abuse Disorders Soap Note NRNP/PRAC 6635

Subjective:

CC (chief complaint): “I am scared. I do not want to be what people say I am”. The patient reports.

HPI: Lisa Tremblay, a 33-year-old female admitted to a detox center in Naples, FL, seeks help from a psychiatrist regarding long-term rehabilitation. While she recognizes that she needs assistance, she has yet to be convinced to join a counseling and rehabilitation home. Her major issue is that she is “scared.”

Assessing and Diagnosing Patients with Substance-Related and Abuse Disorders Soap Note

She is scared about how others see her as an addict. She claims to abuse opiates, costing her around $100 daily. She admits to using cannabis 1-2 times a week (“I have a medical card”) and drinking 1/2 gallon of vodka per day. She also claims that her boyfriend, Jeremy, a cocaine addict, introduced her to crack smoking. She recalls her first crack attempt as being a “hit with a bullet” experience and she felt so amazing and fast that she described it as “dancing with the butterflies.”

She claims that it gets worse and horrible when she does not smoke, a feeling she does not want to return to. She continues to emphasize her craving for crack by stating, “And when I have it, I feel good. And then it’s gone. And then I realize I am going to need another hit.”

She is also scared of rehab, which she perceives as dirty. She is afraid that if she goes to a rehabilitation home, she will not be able to find work or get employed. She gets high enough to remain in the hospital and be cleaned up rather than go to treatment.

Her partner, Jeremy, whom she discovered cheating on her with Alisa, is another source of concern for her. Jeremy was her office friend who did the same work as her-commercials for a local firm. They started a business together and even moved in together, so the prospect of Jeremy cheating bothered her. They lost the business, and Jeremy had depleted their bank accounts for four months to pay for his debts and crack. Linda is concerned about Jeremy’s current drug use since she has never seen him consume drugs before.

They smoke crack together after Jeremy pleads for forgiveness. She also reports that now she does not need aid, as she is fascinated with Jeremy’s assurance that everything would be good. Besides being scared for various reasons, she reports a reduced desire for sleep, sleeping only approximately 5-6 hours each day, a decreased appetite, and a statement that she would rather get high than eat.

Past Psychiatric History:

General Statement: The patient sought detox therapy at a detox clinic in Naples, Florida, intending to pursue long-term rehabilitation.
Caregivers (if applicable): N/A
Hospitalizations: No history of hospitalization
Medication trials: No previous medication trials
Psychotherapy or Previous Psychiatric Diagnosis: The patient has never received any psychotherapy before, and does not have any concurrent psychiatric diagnosis

Substance Current Use and History: She has been abusing opiates, approximately $100 daily. She admits to cannabis 1–2 times weekly and 1/2 gallon of vodka daily. She even has a past drug paraphernalia possession arrest. She reports smoking crack (cocaine), which keeps her calm.

Family Psychiatric/Substance Use History:

Her mother is alive and resides in Maine, with a history of agoraphobia and benzodiazepine abuse. Linda is estranged from her father and lacks his whereabouts, having gone to jail on allegations of sexually assaulting her as well as drug charges. His older brother has had no contact with the family for the last ten years, and he, too, has a history of opiate usage. Linda has a history of opiates, cocaine, cannabis, and alcohol abuse. She has a daughter, Sarah, outside her relationship with Jeremy.

Psychosocial History: She reports sexual abuse as child ages 6-9 and the perpetrator is her father, who went to prison for the abuse and drug charges

Medical History: She has Hepatitis C, which she considers treatment for, but she needs to get clean first. She is hypertensive on admission with a blood pressure of 180/110 mm Hg.

Current Medications: Not currently on any psychiatric or non-psychiatric medications
Allergies: Azithromycin

Reproductive Hx: Heterosexual, no contraceptive use, Para 1+0 non gravida with one living child.

ROS:

GENERAL: Reports slight weight loss and hotness of body. Denies chills, weakness, or fatigue
HEENT: Eyes: Denies visual loss, blurred vision, diplopia, or yellow sclerae. Ears: Denies hearing loss. Nose: Denies congestion, sneezing, and runny nose. Throat: Denies sore throat
SKIN: Denies rashes or itching
CARDIOVASCULAR: Reports palpitations, denies edema, PND, or chest pain
RESPIRATORY: Denies dyspnea, cough, sputum, or hemoptysis
GASTROINTESTINAL: Reports decreased appetite and deny nausea, vomiting, diarrhea, constipation or abdominal discomfort, or swelling
GENITOURINARY: Denies frequency, urgency, nocturia, odor, or change in color
NEUROLOGICAL: Denies headaches, dizziness, syncope, paralysis, ataxia, numbness, or tingling in extremities. No changes in bowel or bladder control
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, joint stiffness, or deformity
HEMATOLOGIC: Denies easy bruising, bleeding, or anemia
LYMPHATICS: Denies lymphadenopathies or history of splenectomy
ENDOCRINOLOGIC: Denies polyuria, polydipsia, polyphagia, cold and hot intolerance, or sweating

Objective:

Physical exam: if applicable

General exam: The patient is in generally fair condition, febrile, and not in any obvious respiratory distress. Vital signs are as follows:

T- 100.0 F

P- 108 beats/minute

R 20 breaths/minute

BP 180/110 mm Hg

Height 5’6

Weight 146lbs

BMI 23.565 kg/m²

Neurological: GCS 15/15. She is oriented to time, person and place. Her sensory and motor systems are intact.

Cardiovascular: Regular rate and rhythm. Precordium is hyperactive. S1 and S2 sounds are present with no additional sounds. Apex is heard at the fifth intercostal space, mid-clavicular line.

Diagnostic results:

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.

Assessment:

Mental Status Examination:

L.T, a 33-year-old female patient who seems older than her age, arrives for psychiatric evaluation dressed in old but neat cloaks. She does not make extended eye contact and is quite fidgety. She talks in a hushed tone and sometimes maintains a lengthy pause before answering questions, even sobbing on one occasion.

When questioned about her mood, she says, “she feels sad and scared about others thinking of her as an addict,” which is consistent with her gloomy affect. Her thought content is filled with depressing cognition in which she believes she is worthless in the eyes of others, while her thought process is logical and coherent.

She has no perception abnormalities. Her memory is clear and intact, and she is oriented to time, person, and place. She has the appropriate judgment and a grade 2 insight, in which she is aware of having a problem and seeking help but denies it at the same time.

Differential Diagnoses:

Stimulant Use Disorder: Primary Diagnosis

The DSM-5 emphasizes numerous aspects important in the diagnosis of stimulant abuse disorders. Cocaine, often known as crack, is a stimulant with the highest potential for abuse, as demonstrated in Linda’s case. To qualify the diagnosis, the stimulant is often used in larger quantities or for a longer length of time than intended (criteria 1), as demonstrated by Linda constantly smoking to remain calm and continuing to smoke so she does not stop feeling good.

Also, the patients demonstrate a persistent desire to cut or regulate the use or make several unsuccessful attempts to reduce use (criteria 2) and demonstrate a significant amount of time to obtain the substance, use it, or recover from its effects (criteria 3) (APA, 2022; Livne et al., 2021). Linda and her partner had depleted all of their financial accounts and lost $80000 in business to get crack and feel high.

In criterion 4, the patient has an extreme need or longing to use the drug, as shown by Linda’s comment, “And then it’s gone. And then I know that I am going to be needing another hit.” Linda’s admission that she feels worse and horrible without cocaine may also reflect withdrawal symptoms, which is criterion 11 of the DSM-5 diagnostic of substance addiction disorder.

Linda’s failed business demonstrates her failure to meet key job obligations (criteria 5). Patients with stimulant use disorders may also take the drug continuously despite persistent social and interpersonal issues, as indicated by Linda’s admission that she cannot get enough even after smoking, implying that she needs more to stay high.

Alcohol Use Disorder: The DSM-5 criteria for all drugs with the potential to be abused cut across. Linda takes a large quantity of vodka daily, half a gallon, which may suggest tolerance, a scenario in which she requires greater amounts (half a gallon) to attain desired results (Kranzler & Soyka, 2018). While alcohol consumption is a glaring issue in the patient, diagnosing alcohol use disorder may be irrational due to the lack of substantial details demonstrating considerable impairment in control and social life related to alcohol.

Opioid Use Disorder: The patient takes enormous quantities of opioids costing $100 each day; nevertheless, all of the other symptoms seen in her, such as craving, a great deal of time and effort to obtain a drug, tolerance, and withdrawal symptoms, are related to cocaine use, ruling out opioid use disorder as a primary diagnosis.

Cannabis Use Disorder: The patient admits to using cannabis 1-2 times a week but claims to have a medical card for cannabis use, implying that the use is medically justified. Furthermore, the quantity and frequency variable associated with cannabis use are statistically significant in the diagnosis of cannabis use disorder (Callaghan et al., 2020); consequently, Linda, who only uses cannabis 1-2 times per week, may have a low risk of developing cannabis use disorder.

Reflections:

Each psychiatric case is distinct, posing a new challenge to validate the diagnosis using the DSM-5 criteria. Concerning substance use disorders, I have learned about the many medications that have the potential to be misused, as well as how a comparable diagnostic criterion is applied for all of them.

Adults may be easier to gain informed consent from owing to their legal age of informed consent; yet, their mental state may prevent them from making treatment decisions, requiring the use of a proxy person to act on their behalf. In the future, I will invite the patient to come in with a family member or spouse who knows them better and can provide a more accurate account of their mental disease.

A doctor must protect the patient’s privacy and confidentiality, which includes not disclosing the psychiatric diagnosis to the patient’s spouse (Bipeta, 2019). Suppose Linda wants her information shared with her husband, and the confidentiality provision is violated. Then formal informed consent should be acquired from her, including authorization to divulge how much, which should be included in the patient’s records (Bipeta, 2019).

Because Linda and her partner are both drug addicts, they may want to consider joining support groups like Alcoholics Anonymous to help them remain clean, as well as a measure of health preventive and promotion techniques to avoid further consequences of the drugs abused.

Assessing and Diagnosing Patients with Substance-Related and Abuse Disorders Soap Note References

American Psychiatric Association. (2022). Substance-related and addictive disorders. In Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787.x16_substance_related_disorders

Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of Psychological Medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Callaghan, R. C., Sanches, M., & Kish, S. J. (2020). Quantity and frequency of cannabis use in relation to cannabis-use disorder and cannabis-related problems. Drug and Alcohol Dependence, 217(108271), 108271. https://doi.org/10.1016/j.drugalcdep.2020.108271

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: A review. JAMA: The Journal of the American Medical Association, 320(8), 815–824. https://doi.org/10.1001/jama.2018.11406

Livne, O., Shmulewitz, D., Stohl, M., Mannes, Z., Aharonovich, E., & Hasin, D. (2021). Agreement between DSM-5 and DSM-IV measures of substance use disorders in a sample of adult substance users. Drug and Alcohol Dependence, 227(108958), 108958. https://doi.org/10.1016/j.drugalcdep.2021.108958

Assessing and Diagnosing Patients with Substance-Related and Abuse Disorders Soap Note Instructions

Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders

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.
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.

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.).

Assessing and Diagnosing Patients with Substance-Related and Abuse Disorders Soap Note 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://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-82