Running head: ASSESSING AND DIAGNOSING PATIENTS WITH SUBSTANCE 1

Week #8: Assessing and Diagnosing Patients With Substance-Related and Addictive

Disorders

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

Subjective

CC (chief complaint): Ms. Lisa Pittman presents herself thinking about long term rehabilitation

so that she can consider treatment for her Hep C+.

HPI: Lisa Pittman is a 29 year old woman who presents herself for rehabilitation after her

struggles with addiction. She admits to cannabis 1–2 times

weekly and goes ahead and states that “I have a medical card”, and 2–3 alcohol drinks once

weekly.

Past Psychiatric History:

 General Statement: The patient has never been treated before and is in fact doing it for the

first time.

 Caregivers (if applicable): The patient has no close helper who looks after her.

 Hospitalizations: Ms. Lisa Pittman has never been psychiatrically hospitalized.

 Medication trials: The patient Lisa Pittman has been undergoing randomized drug screens.

No medication was prescribed.

 Psychotherapy or Previous Psychiatric Diagnosis: Psychotropic medications have never been

prescribed for Ms. Lisa Pittman. Past psychiatric history is otherwise entirely negative.

Substance Current Use and History: The patient has been smoking crack cocaine,

approximately $100 daily. She admits to cannabis 1-2 times weekly and has a “medical card”.

She also consumes 2-3 alcohol drinks once in a week.

Family Psychiatric/Substance Use History: Mother known to have history with anxiety and

benzodiazepine use. Older brother has history with opioid use. Father was also imprisoned for

drug and substance use.

Psychosocial History: The patient is a 29 year old female and lives in a West Palm Beach, FL

detox facility. She used to live with both her parents until her father was convicted of raping her

during ages 5-7 and was sepearted fom her. Her mother lives in Alabama while older brother has

not been in contact with family in last 10 years. The patient has past drug possession and theft

convictions and is currently on a 2 year probation with randomized screens.

Medical History: The patient has no medical history.

 Current Medications: Ms. Lisa is not on any medication at the moment.

 Allergies: The patient has an allergy in medication that contains amoxillin.

 Reproductive Hx: The patient has no known reproduction history

ROS:

 GENERAL: Loss of appetite.

 HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose,

Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat

 SKIN: No rash or itching

 CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or

edema.

 RESPIRATORY: No shortness of breath, cough, or sputum

 GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or

blood.

 GENITOURINARY: No burning on urination, urgency, hesitancy, odor, odd colour

 NEUROLOGICAL: No headache dizziness syncope paralysis ataxia numbness or tingling in

the extremities. No change in bowel or bladder control.

 MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness

 HEMATOLOGIC: No anemia, bleeding, or bruising

 LYMPHATICS: No enlarged nodes. No history of splenectomy

 ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or

polydispia

Objective:

Physical exam: Ms. Lisa Pittman presents as silent person who thinks likes time alone thinking.

Diagnostic results:

Assessment:

Mental Status Examination: During the interview the patient was cooperative. She had a

normal speech rate and auditory or visual hallucianation. The patient could be have an avoidant-

restrictive food intake disorder, which lead her to undereat because she lacked interest in food

and preferred getting high. Such a disorder can make the patient experience significant

nutritional deficieny. The disorder may be as a result of psychosocial interference and other life

disturbances.

Differential Diagnoses

Anxiety.

The diagnosis is due to the presence of excessive anxiety for a long period of time .

Anxiety patients have other symptoms such as restlessness, impaired concentration, irritability

and difficulty in sleeping(Perrotta,2020). Additionally, the patient can have trouble

concentrating or thinking about something important. Instead, patients with anxiety tend to worry

about the current situation. As such, differential diagnosis of anxiety with mood disorders can be

difficult. Lisa is worried about her medical results and focused on making sure that she does not
ASSESSING AND DIAGNOSING PATIENTS WITH SUBSTANCE 5

test dirty urine. It is clear that Lisa finds it difficult to abandon use of drugs despite her interests

in making significant progress with her medication.

Panic Disorder (PD)

Patients with panic disorder experience both panic attacks and anticipatory anxiety. The

disease in PD Panic Attacks are not due to the direct physiological effects of a substance or

general medical conditions(Oquendo,Bernstein, & Mayer,2019). Mostly, panic disorder can be

characterized by excessive fear that one may experience another panic attack after experiencing

an attack. Panic attacks mostly result in tense fear that can occur abruptly without any warning.

Notable symptoms may include fear of death, changes in mental state, and tingling in hands.

Patients with PD withdraw to avoid physiological states or stimuli. Lisa fears about her health

condition and is determined to get clean first. She could panic in case eh receives worse medical

results regarding her condition.

Posttraumatic Stress Disorder

Patient with posttraumatic stress disorder (PTSD) experience experience symptoms, such

as flashbacks and disturbing images. Additionally, such patients can have unwarranted

distressing memories, upsetting dreams and nightmares regarding a particular traumatic event

that occurred in their lives. Patients with PTSD can also have severe emotional distress. They

can also physically react to something disturbing them in their mind. However, the primary

between pots-traumatic stress disorder with other anxiety related to anxiety is that it is

accompanied with physical disorder (Hantsoo & Epperson,2017). Patients have recurrent and

distressing recollections of the event which the patient lacks. Lisa is suffering from PTSD due

toher past relationship with her father, where she was raped. Additionally, PTSD could be the
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leading cause for the indulgence in drug and substance abuse. Poor relationship with close family

member’s could also be the leading cause for Lisa’s PTSD.

Reflections:

Mrs. Lisa Pittman is sad looking, inattentive, unhappy but exhibits normal speech rate

and her language skills are intact. She has no apparent signs of hallucinations, delusions or any

bizarre behaviors with her cognitive functions remaining normal. She appears to be having

sleeping challenges and an avoidant-restrictive food intake disorder, due to her seemingly weak

body. However, having consistent check-ups would prove essential in case of any conditions that

might significantly affect her overall well-being.

References

Hantsoo, L., & Epperson, C. N. (2017). Anxiety disorders among women: a female lifespan

approach. Focus, 15(2), 162-172.

Oquendo, M. A., Bernstein, C. A., & Mayer, L. E. (2019). A key differential diagnosis for

physicians—major depression or burnout?. JAMA psychiatry, 76(11), 1111-1112.

Perrotta, G. (2020). Borderline personality disorder: Definition, differential diagnosis, clinical

contexts, and therapeutic approaches. Annals of Psychiatry and Treatment, 4(1), 043-056.