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

Video Title 82 Transcript

00:00:00

BEGIN TRANSCRIPT:

00:00:00

[sil.]

00:00:20

LISA Well I had to be here in this hospital if that answers your question.

00:00:25

Psychiatrist: Yes, thank you. Can I get you a drink of water or something else to drink? Anything?

00:00:35

LISA: A drink isn’t going to convince me, right? You’re going to have to convince me.

00:00:40

Psychiatrist: What is you want me to persuade you to do?

00:00:45

LISA Going to rehab.

00:00:50

Psychiatrist: What worries you about going to rehab?

00:00:55

[sil.]

00:01:00

LISA Everything.

00:01:00

Psychiatrist: Okay. I tell you what let’s go back a little bit and tell me about how you’re feeling today.

00:01:10

LISA Scared.

00:01:15

Psychiatrist: Can you tell me more about that feeling of being scared?

00:01:20

LISA Well, I don’t want to be. I don’t want to be what people say I am because if I say it and I’m not going to say it because I ain’t going to change. I can’t.

00:01:35

Psychiatrist: What do people say you are?

00:01:40

LISA And I’m not.

00:01:45

Psychiatrist: What don’t you want to be?

00:01:45

LISA An addict.

00:01:50

Psychiatrist: Do you use drugs and alcohol?

00:01:50

LISA Yeah sometimes I have a drink. You know with friends [inaudible] but it doesn’t matter. I’m in control.

00:02:00

Psychiatrist: Do you feel in control now?

00:02:05

LISA Maybe I could just get that drink [inaudible].

00:02:10

Psychiatrist: Sure. Sure. Here you go.

00:02:15

LISA Thank you.

00:02:20

[sil.]

00:02:30

LISA You know what I just think I should leave.

00:02:30

Psychiatrist: You keep saying you should leave. You said that earlier but do you really want to leave?

00:02:40

LISA No.

00:02:45

Psychiatrist: Okay. Tell me why you are here.

00:02:45

LISA Because I’m scared.

00:02:50

Psychiatrist: You said that earlier. You think if you could — then I could figure out together why you’re scared and maybe we can come up to a plan. Up with a plan and if we do that, then maybe your fears will disappear.

00:03:05

LISA No not these fears [inaudible] because it’s over.

00:03:10

Psychiatrist: What’s over?

00:03:10

LISA Everything. The business.

00:03:15

Psychiatrist: What do you mean?

00:03:20

LISA Jeremy.

00:03:25

Psychiatrist: Who is Jeremy?

00:03:25

LISA He’s my boyfriend. I saw him naked with Alisa [assumed spelling] with the same fucking name as me. We now have the same fucking boyfriend. In my office, he was screwing that fucking cunk.

00:03:45

Psychiatrist: So you’re the one who caught Jeremy cheating?

00:03:55

LISA Yeah. Cheating? Yeah that’s a clever word shrinks use.

00:04:05

Psychiatrist: So you and Jeremy share an office?

00:04:05

LISA Yeah we do commercials for local businesses, you know, build websites, that kind of stuff. We started a business together. He moved in with me.

00:04:15

Psychiatrist: How long ago was that?

00:04:20

LISA Nine months.

00:04:20

Psychiatrist: Do you have any children?

00:04:20

LISA Not with that fucking asshole.

00:04:25

[sil.]

00:04:30

LISA I have a daughter, Sarah. Gosh, she’s beautiful. She stays with some friends. She’s not related to Jeremy, thank God.

00:04:45

Psychiatrist: And where are you staying?

00:04:45

LISA I’m renting a place far away from here. You know I ran down to the bank to empty both our bank accounts.

00:04:55

Psychiatrist: Business accounts?

00:04:55

LISA Yeah. And do you know that asshole has been draining them for 4 months? I swear.

00:05:05

Psychiatrist: Taking money out of your account without your knowledge.

00:05:05

LISA Yeah. For his buys.

00:05:10

Psychiatrist: Buys?

00:05:10

LISA Yeah, to payoff his debts with my money.

00:05:20

Psychiatrist: Or crack cocaine?

00:05:25

LISA Yeah for crack.

00:05:25

Psychiatrist: How long have you know he’s been smoking crack?

00:05:30

LISA Ever since I saw him with that — every since I saw with her naked. The both of them naked.

00:05:40

Psychiatrist: What was that like seeing Jeremy and Alisa naked and smoking crack?

00:05:40

LISA Well have you ever seen someone you love naked smoking crack?

00:05:45

Psychiatrist: No.

00:05:50

LISA Yeah no I didn’t think so.

00:05:50

Psychiatrist: So what has that been like for you knowing Jeremy’s smoking crack?

00:05:55

LISA Well, I’ve never seen him do drugs before. You know he drinks a lot, smokes weed, but crack cocaine. I mean God have mercy.

00:06:15

Psychiatrist: What are you thinking about?

00:06:20

LISA Everyone’s going to know.

00:06:25

Psychiatrist: Know what?

00:06:30

LISA That I was getting high to stay in this hospital and get cleaned up.

00:06:35

Psychiatrist: You mean rather than go to rehab.

00:06:40

LISA Rehab, man they’re fucking dirty places and I’m sick and tired of dirty places.

00:06:45

Psychiatrist: No, no, no this rehab place is very clean. I’ve seen it. There are a lot of nice people there. People who feel like they get much better help than here in the hospital. In fact, I can call someone for you and let you talk with them.

00:06:55

LISA No, no, no, no, no, no, no, no, don’t do that.

00:07:00

Psychiatrist: You’re really fearful of going to rehab.

00:07:05

LISA Well if everyone finds out that I’ve been to rehab, I won’t get a job. I won’t be hired anyway.

00:07:10

Psychiatrist: Plus if people are fearful of the stigma and fearful of what people will think of them.

00:07:20

LISA Yeah, but he says that I’m not addicted. It’s just — you know something wrong with my personality.

00:07:25

Psychiatrist: Who says there’s something wrong with your personality?

00:07:30

LISA Jeremy.

00:07:30

Psychiatrist: When did he tell you that?

00:07:35

LISA Lots of times.

00:07:35

Psychiatrist: I thought you said you and Jeremy split up after you caught him cheating.

00:07:40

LISA I —

00:07:45

Psychiatrist: It’s okay. Take your time.

00:07:50

LISA Well yeah he moved back in.

00:07:50

Psychiatrist: Into your new home?

00:07:55

LISA Yeah. What changed that you two decided to get back together?

00:08:00

Psychiatrist: Well he said he was sorry and he begged me. He’s done it before so I took him back.

00:08:10

LISA And how has that been being back with Jeremy?

00:08:15

Psychiatrist: Well I love Jeremy. I do and don’t want to go out and find another boyfriend. I mean we lost 80,000 dollars on that business. And he promised me that he would make it all back.

00:08:30

LISA So is that why you took him back? Has Jeremy continued smoking crack?

00:08:45

Psychiatrist: Yeah a little but he’s not addicted. He says that it calms him down. Me too.

00:09:05

LISA You too?

00:09:05

Psychiatrist: So do you smoke crack with Jeremy?

00:09:15

LISA Yeah we — he made me try it.

00:09:25

[sil.]

00:09:30

[ Crying ]

00:09:40

LISA And then he tried just once. We did it together. [Inaudible] I could.

00:09:55

[ Crying ]

00:10:00

LISA Hit me like a bullet. And it felt so good. I felt so good. And real fast.

00:10:20

[sil.]

00:10:25

LISA Have you ever felt like you were dancing with butterflies?

00:10:30

Psychiatrist: Dancing with butterflies? No I have not.

00:10:40

[sil.]

00:10:45

LISA But he says it’s not addictive, Jeremy.

00:10:50

Psychiatrist: What do you think?

00:10:55

LISA Well I know I can’t get enough.

00:11:00

[ Crying ]

00:11:10

LISA And I know I don’t want to go back to feeling horrible again because when I don’t smoke it I get worse. And when I have it, I feel good. And then it’s gone. And then I know that I’m going to be needing another hit.

00:11:45

Psychiatrist: That sounds a lot like addiction.

00:11:55

LISA Yeah but I know I don’t want it to be.

00:12:00

Psychiatrist: It sounds like you are very scared of getting help and yet at the same very time, it sounds like you know you need that help.

00:12:15

LISA I know I don’t need help. I don’t need anything. Jeremy promised me that everything is going to be okay. And when you love someone like I do, you got to believe him. Right?

00:12:45

[sil.]

00:12:45

END TRANSCRIPT

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

  Excellent Good Fair Poor
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
Points Range:18 (18.00%) – 20 (20.00%)The response thoroughly 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. Points Range:16 (16.00%) – 17 (17.00%)The response 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. Points Range:14 (14.00%) – 15 (15.00%)The response 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, but is somewhat vague or contains minor innacuracies. Points Range:0 (0.00%) – 13 (13.00%)The response provides an incomplete or inaccurate description of 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. Or, subjective documentation is missing.
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.
Points Range:18 (18.00%) – 20 (20.00%)The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. Points Range:16 (16.00%) – 17 (17.00%)The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. Points Range:14 (14.00%) – 15 (15.00%)Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. Points Range:0 (0.00%) – 13 (13.00%)The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
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.
Points Range:23 (23.00%) – 25 (25.00%)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. Points Range:20 (20.00%) – 22 (22.00%)The response 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 an accurate justification for each of the disorders selected. Points Range:18 (18.00%) – 19 (19.00%)The response documents the results of the mental status exam with some vagueness or innacuracy.Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy. Points Range:0 (0.00%) – 17 (17.00%)The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.
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.). Points Range:9 (9.00%) – 10 (10.00%)Reflections are thorough, thoughtful, and demonstrate critical thinking. Points Range:8 (8.00%) – 8 (8.00%)Reflections demonstrate critical thinking. Points Range:7 (7.00%) – 7 (7.00%)Reflections are somewhat general or do not demonstrate critical thinking. Points Range:0 (0.00%) – 6 (6.00%)Reflections are incomplete, inaccurate, or missing.
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). Points Range:14 (14.00%) – 15 (15.00%)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. Points Range:12 (12.00%) – 13 (13.00%)The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. Points Range:11 (11.00%) – 11 (11.00%)Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. Points Range:0 (0.00%) – 10 (10.00%)Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.
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.
Points Range:5 (5.00%) – 5 (5.00%)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. Points Range:4 (4.00%) – 4 (4.00%)Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive.Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Points Range:3.5 (3.50%) – 3.5 (3.50%)Purpose, introduction, and conclusion of the assignment is vague or off topic.Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%-79% of the time. Points Range:0 (0.00%) – 3 (3.00%)No purpose statement, introduction, or conclusion were provided.Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.
Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and punctuation
Points Range:5 (5.00%) – 5 (5.00%)Uses correct grammar, spelling, and punctuation with no errors Points Range:4 (4.00%) – 4 (4.00%)Contains a few (one or two) grammar, spelling, and punctuation errors Points Range:3 (3.00%) – 3 (3.00%)Contains several (three or four) grammar, spelling, and punctuation errors Points Range:0 (0.00%) – 2 (2.00%)Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding