Assessing and Diagnosing Patient with Substance Related Disorder

Patient Information: Initials: KB Gender: F Age: 41

Patient: Training Title 151

Subjective:

CC: elbow pain

HPI: BK is a 41 year old Caucasian female who is being assessed by a psychiatrist for the possibility of substance abuse. In order to relieve the pain she is experiencing from chronic elbow pain, she has been experimenting with various medications to help her cope. She did mention that she was also suffering from headaches, which drove her to use pain relievers. According to the information provided by the patient, it is clear that she has been suffering from pain, which has prompted her to experiment with several types of medicines that have failed to bring relief, prompting her to look into other drug forms. She reports that the other drugs she was taking caused her to undergo problems like constipation and dizziness, and, more importantly, they did not relieve her pain in the way she had hoped they would have. She bases her views on such perspectives when discussing the effects of drugs like Morphine and Dilaudid, which she claims seldom helped in terms of suppressing the pain she was experiencing Assessing and Diagnosing Patient with Substance Related Disorder.

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Past Psychiatric History:

Denies any past mental history

  • General Statement: The patient is here to be assessed for probable substance abuse, and this is her first visit to a psychiatrist.
  • Caregivers (if applicable): none
  • Hospitalizations: denies any prior hospitalizations
  • Medication trials: denies past psychiatric Adderall abuse in the past.
  • Psychotherapy or Previous Psychiatric Diagnosis: Denies any past psycho Reports biofeedback in the past.

Substance Current Use and History: Patient has used a variety of substances, including alcohol, cannabis for headache relief, and Tylenol with codeine, which resulted in a flushed response. Ecstasy and LSD were used once or twice, with no adverse outcomes. Cocaine was used 1-2 months ago, Adderall 20mg was not prescribed.

Family Psychiatric/Substance Use History: No family history or substance abuse.

This information is critical in determining the patient’s medical history and in providing her with the most effective treatment possible.

Psychosocial History:

Katarina has two brothers and two sisters. She has a part-time job as a cashier at Aldi Grocery Store. She left high school when I was in the eleventh grade. She is a single woman with a boyfriend. In addition to having a son with whom she has been denied custody, she also has parents who are addicted to drugs. She consumes alcoholic beverages 1-2 times a week, when she is with family or on specific events. When she is with her lover, she drinks to the point of being inebriated, culminating in a DUI. She claims that she takes marijuana four times a week to alleviate her headaches.

Medical History: Assessing and Diagnosing Patient with Substance Related Disorder

  • Current Medications: Fish oil and vitamins

Allergies: Codeine

  • Reproductive Hx: She does not affirm or deny having sexual contact with her lover. Regular menstrual cycle.
  • Past Medical History: Chronic Pain

 

ROS:

GENERAL: Denies weight loss, fever, and chills.

HEENT: Denies visual problems, hearing problems and ear pain. Denies sinus problems. Denies neck pain or injury.

SKIN: Denies rash, itching or lesions.

Cardiovascular/Peripheral Vascular: Denies chest pain, heart palpitations, murmurs, or edema.

RESPIRATORY: Denies breathing problems.

GASTROINTESTINAL: Normal bowel movements. Denies anorexia, nausea or vomiting.

GENITOURINARY: No pain or urinary changes.

NEUROLOGICAL: Positive for irregular sleeping patterns. Denies sleeplessness, reduced energy, and suicidal ideation.

MUSCULOSKELETAL: Denies back pain, muscle pain, joint pain or swelling. HEMATOLOGY: Denies anemia, bleeding, or bruising.

LYMPHATICS: Denies enlarged nodes, or history of splenectomy

ENDOCRINE: Denies heat or cold intolerance, or sweating.

Allergic/Immunologic: Denies asthma, hives or immunologic condition.

Objective:

Physical exam:

Vitals: T- 97.4 P- 74 R 120 100/70 Ht 5’8 Wt 117lbs

Diagnostic results: CBC, CMP, UDS.

Among the numerous innovative procedures developed by Skinner (1982) was the objective of detecting drug abuse. The screening tool, referred to as the Drug Abuse Screening Test (DAST-10) is used to determine whether or not someone is abusing drugs (Shirinbayan et al., 2020). When it comes to clinical contexts, the DAST is a quick and simple test. Additionally, it can be utilized to assess the effectiveness of the treatment Assessing and Diagnosing Patient with Substance Related Disorder.

Assessment:

Mental Status Examination:

Client seems uneasy, fidgety, and easily disturbed, but he is alert and oriented x4. She is gentle and cooperative with the interviewer. She is properly attired and well groomed for the occasion. Gait is steady.   Her speech is coherent and clear; her tone is normal and she is able to communicate her ideas and emotions via her words. She has a fair insight of sickness. During the interview, the client exhibits a flat demeanor sometimes and seems suspicious at other times. There are no outward indicators of delusion, hallucination, or paranoia. The thought process is logical, and the contents of her thoughts is appropriate. Has a fair judgment. She has exceptional short- and long-term memory, and she is able to focus. The mood is euthemic.  Denies SI, HI, VH, AH. Differential Diagnoses:

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Substance Use Disorder with severe opioid use disorder [F11.20]:

The DSM-5 acknowledges the existence of substance-related disorders caused by the consumption of a total of ten distinct kinds of drugs: alcohol, cocaine, methamphetamine, and opiates, among others (APA, 2013).  The client takes an opioid and claims that it is more effective in alleviating her elbow pain. She has also experimented with other substances such as cannabis, alcohol, caffeine, cocaine, and other drugs.

Alcohol Use Disorder with severe use: [F10.20].

AUD is a psychiatric illness that is defined by a poor capacity to quit or regulate alcohol use notwithstanding the negative implications of alcohol consumption on one’s social, vocational, and health lives. In certain circles, it is referred to as “alcohol abuse,” “alcohol dependency,” or “alcohol addiction,” while others use the word “alcoholism” (Takahashi et.al, 2017) Assessing and Diagnosing Patient with Substance Related Disorder

Stimulant Use Disorder Moderate: [F15.20]:

Neuroadaptation and the impact of drug use on one’s ability to function socially and in relationships are taken into account while establishing the criteria for stimulant use disorder. In this case, the client has tried cocaine and Adderall, leading to the probability of the above-mentioned diagnosis being made.

Reflections:

When I first started looking into Bykov’s case, I was especially worried about the severe health impacts of illicit drugs. In this scenario, the first thing I considered was that legal drug usage is equally as harmful as illegal drug use since these medications are addictive. Bykov’s case clearly demonstrates that the majority of people who suffer from substance addiction do not realize they have the condition until it is severe. Considering the ease with which people suffering from chronic pain may get and utilize such drugs, it is necessary that such substances be subjected to stringent regulations in terms of their usage.

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References

American Psychiatric Association. (2013). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Shirinbayan, P., Salavati, M., Soleimani, F., Saeedi, A., Asghari-Jafarabadi, M., Hemmati- Garakani, S., & Vameghi, R. (2020). The Psychometric Properties of the Drug Abuse Screening Test. Addiction & health, 12(1), 25–33. https://doi.org/10.22122/ahj.v12i1.256

Skinner H. A. (1982). The drug abuse screening test. Addictive behaviors, 7(4), 363–371. https://doi.org/10.1016/0306-4603(82)90005-3

Takahashi, T., Lapham, G., Chavez, L. J., Lee, A. K., Williams, E. C., Richards, J. E., Greenberg, D., Rubinsky, A., Berger, D., Hawkins, E. J., Merrill, J. O., & Bradley, K. A. (2017). Comparison of DSM-IV and DSM-5 criteria for alcohol use disorders in VA primary care patients with frequent heavy drinking enrolled in a trial. Addiction science & clinical practice, 12(1), 17. https://doi.org/10.1186/s13722-017-0082-0

Subjective: Assessing and Diagnosing Patient with Substance Related Disorder

CC (chief complaint):

HPI:

Past Psychiatric History:

  • General Statement:
  • Caregivers (if applicable):
  • Hospitalizations:
  • Medication trials:
  • Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

 

  • Current Medications:
  • Allergies:
  • Reproductive Hx:

ROS:

  • GENERAL:
  • HEENT:
  • SKIN:
  • CARDIOVASCULAR:
  • RESPIRATORY:
  • GASTROINTESTINAL:
  • GENITOURINARY:
  • NEUROLOGICAL:
  • MUSCULOSKELETAL:
  • HEMATOLOGIC:
  • LYMPHATICS:
  • ENDOCRINOLOGIC:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

Assessing and Diagnosing Patient with Substance Related Disorder