NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Subjective:

Name: A. P

Gender: Female

Age: 48 years old

CC (chief complaint): Client’s supervisor, “Ms. Ally’s alcohol consumption, is getting out of

hand. I suspect a potential substance use.”

HPI:

Ally is a 48-year-old female who is undergoing psychiatric assessment after a referral from the school EAP counselor as a result of her substance abuse probability. The client has been late for classes for 22 days due to excessive alcohol consumption and was referred to facilitate getting her help and retaining her at the school. The patient reports that she was late to work on the interview day since she attended a party the previous evening and drank too much. She initially denies that she got intoxicated and passed out but later admits it. The client reports that she drinks too much every night. She states that she mostly drinks alone but occasionally goes to a bar with her friends or drink at school functions, where the alcohol supply is liberal. She also reports taking 5-6 glasses of wine and several mixed drinks when her students give her a rough time.

The client attributes the excessive drinking to the stress she experiences at school due to students’ indiscipline. She admits to taking too much alcohol but states that it affects her differently. She admits to passing out severally when drunk. Students and parents have complained that Ally has severally gotten to class to teach while drunk, but she denies the claims. According to her students, she goes to class drunk and orders them to read from their textbook or copy notes from the board while sleeping with her head on the desk. Her drinking behavior puts her at risk of losing her teaching job, and the Board of Education may dismiss her if she does not cooperate during the psychiatric evaluation.

Past Psychiatric History:

  • General Statement: No psychiatric history.
  • Caregivers: None
  • Hospitalizations: No history of psychiatric hospitalization.
  • Medication trials: None
  • Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History:

She has a history of alcohol consumption since she was a teenager. Alcohol consumption has increased over the years. She reveals taking on average 5 wine glasses alongside some mixed drinks in order to get high. She takes 5-6 glasses of wine and a handful of mixed drinks to get intoxicated.

Family Psychiatric/Substance Use History: The client’s father was an alcoholic. He got into Alcohol Anonymous and quit alcohol.

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Psychosocial History:

Ally was born alone and her parents raised her within the San Francisco area in Carlifonia. She possesses a PhD majoring in Biology while also having a Masters in high school education. Her current employment is in high school. Ally reports being currently in a relationship.

Medical History:

 

  • Current Medications: None
  • Allergies: No food or drug allergies.
  • Reproductive Hx: Para 0+0; No history of gynecologic disorders. LMP-3 weeks ago.

ROS:

  • GENERAL: Lacks chills, fever, fatigue or weight changes.
  • HEENT: Denies traumatic head injury, eye pain, blurred vision, ear discharge, hearing loss, sneezing, nasal discharge, sore throat, or hoarse voice.
  • SKIN: Negative for skin rashes, itching, bruises, or lesions.
  • CARDIOVASCULAR: Denies palpitations, chest pain, SOB on exertion, orthopnea, or edema
  • RESPIRATORY: Does not have cough, sputum production, dyspnea, or chest pain.
  • GASTROINTESTINAL: Denies rectal bleeding, vomiting, nausea, constipation, abdominal discomfort, or diarrhea.
  • GENITOURINARY: Negative for pelvic pain, excessive or malodorous vaginal discharge, dysuria, or urine color changes.
  • NEUROLOGICAL: Negative for headache, fatigue, drowsiness, LOC, or burning sensations.
  • MUSCULOSKELETAL: Denies muscle pain, joint pain/stiffness, or joint enlargement.
  • HEMATOLOGIC: Denies bruising or history of blood transfusion.
  • LYMPHATICS: Does not have a history of lymph node enlargement.
  • ENDOCRINOLOGIC: Rejects excessive hunger, polyuria, and thirst, or excessive sweating.

Objective:

Physical exam:

BP: 122/76; HR- 84; RR-20; Temp- 98.24

Ht- 5’4; Wt- 138 lbs.

Diagnostic results: No labs or imaging tests were ordered.

Assessment:

Mental Status Examination:

The client is neat and dressed appropriately for the weather and function. She is alert but appears a bit confused and

NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

anxious and maintains limited eye contact. Her speech is clear at a normal rate, but the volume increases when she gets provoked. She demonstrates a congruent thought process. No hallucinations, delusions, obsessions, homicidal, or suicidal ideations were noted. She is oriented to time, person, and place, and also manifests good judgment. Memory is intact. Insight is present.

Differential Diagnoses:

Alcohol Use Disorder

Alcohol use disorder (AUD) is defined to as a maladaptive pattern associated with substance use that leads to the clinical impairment or distress of an individual. According to the DSM-V, the presence of certain symptomatology such as extended alcohol use in large amounts, inability to reduce alcohol intake, expending time on alcohol related activities, and craving for alcohol indicate the condition (APA, 2013). Moreover, using the alcohol recurrently thus impairing social and economic functions and the usage of alcohol despite its social detriments also lend to the presence of alcohol use disorder (Yang et al., 2018). Besides, fundamental occupational, social, or recreational activities are given up or reduced due to imbibing on alcohol. Lastly, obsession with alcohol does not reduce despite its exacerbation of physical or psychological manifestations.

AUD is a differential diagnosis based on the client’s history of taking large amounts of alcohol; Spending lots of time taking alcohol; recurrent alcohol use resulting in failure to carry out her teaching obligations; and continuing to take alcohol despite it causing problems in her relationships.

Generalized Anxiety Disorder

The client could be having GAD based on her report of getting stressed due to student indiscipline at school. The alcohol intake could result from GAD since she reports taking alcohol when her students take the edge off the day (McHugh & Weiss, 2019). Besides, the client appears anxious and is inattentive during the interview, which is consistent with GAD.

Major Depressive Disorder

Major depressive disorder (MDD) is a differential diagnosis based on the client’s history of losing interest in her job. The client’s alcohol problem could be secondary to depression (McHugh & Weiss, 2019). However, she does not demonstrate other symptoms of MDD.

Reflections:

If I were to conduct the session again, I would assess the client’s history of using other drug substances to rule out the presence of a substance abuse disorder. I would also order a urine test to evaluate if the client has been using other illicit drugs (Kranzler & Soyka, 2018). Legal and ethical considerations for this client include autonomy, beneficence, nonmaleficence, and confidentiality. The PMHNP should respect the client’s decision regarding her care to uphold autonomy.  Beneficence and nonmaleficence should be upheld by choosing treatment interventions to promote the best possible health outcomes and not harm the client. In addition, the PMHNP should ensure that the client’s information is not shared with other persons without the client’s consent. The client’s health promotion strategies should focus on reducing alcohol consumption and help her return to normal functioning.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review. JAMA320(8), 815–824. https://doi.org/10.1001/jama.2018.11406

McHugh, R. K., & Weiss, R. D. (2019). Alcohol Use Disorder and Depressive Disorders. Alcohol research: current reviews40(1), arcr.v40.1.01. https://doi.org/10.35946/arcr.v40.1.01

Yang, P., Tao, R., He, C., Liu, S., Wang, Y., & Zhang, X. (2018). The Risk Factors of the Alcohol Use Disorders-Through Review of Its Comorbidities. Frontiers in neuroscience12, 303. https://doi.org/10.3389/fnins.2018.00303