Many individuals seeking treatment meet the criteria for both mental health and substance-related disorders. Regardless of whether you specialize in substance-related disorders, all advanced practice nurses should know their signs and symptoms and how to assess and diagnose them. There are assessment and screening tools available to clinicians, and a plethora of information can be obtained through the diagnostic interview. It takes time and experience to know what types of questions to ask to gain the most information, in addition to a basic knowledge of the substances and behaviors you are trying to assess. It can be complicated to sort out substance use disorders from other mental health disorders, but most clients seeking treatment have comorbidities.
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis. (Comprehensive psychiatric evaluation template to be use is in an attachment file)
*transcript of case is attached to file
*Background information to be used in case is attached to file
* peer-review scholarly journals to be used, no older than 3 years and current DSM-5-TR 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.).
Expert Solution Preview
Introduction: As an advanced practice nurse, it is important to be able to assess and diagnose both mental health and substance-related disorders, as many patients seeking treatment have comorbidity. In this assignment, we will be completing a comprehensive psychiatric evaluation for a patient with symptoms related to both mental health and substance use disorders. We will use a template provided and incorporate the patient’s background information as well as peer-reviewed scholarly journals to formulate our differential diagnosis and primary diagnosis.
Subjective: The patient presented with a chief complaint of feeling down and hopeless, as well as experiencing cravings for opioids. They reported a duration of symptoms for several months, with severity impacting their ability to work and maintain relationships. The patient also reported a history of depression and anxiety.
Objective: During the psychiatric assessment, the patient appeared disheveled and had poor eye contact. They exhibited slowed speech and movements. The patient displayed symptoms of depression, including low mood, loss of interest in activities, and feelings of worthlessness. Additionally, the patient displayed symptoms of opioid withdrawal, including dilated pupils, restlessness, and muscle aches.
Assessment: The patient’s mental status examination indicated symptoms of depression and opioid use disorder. Differential diagnoses include depression with comorbid opioid use disorder, opioid-induced mood disorder, and substance-induced mood disorder. Based on the DSM-5-TR criteria, the differential diagnosis of opioid-induced mood disorder was ruled out. The critical-thinking process led to the primary diagnosis of depression with comorbid opioid use disorder. Pertinent positives include the patient’s history of depression, while pertinent negatives include no reported suicide or self-harm ideation.
Reflection notes: If conducting the session over, it would be important to obtain a more detailed substance use history, including frequency, amount, and duration of opioid use. Legal and ethical considerations include obtaining informed consent for treatment and maintaining confidentiality. Health promotion and disease prevention should take into consideration the patient’s age, ethnic group, PMH, and socioeconomic and cultural background. Risk factors such as unemployment and a history of substance abuse may also impact treatment planning.
