Assignment: Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders

 



As an advanced practice nurse, it is important to know how to assess and diagnose patients with substance-related and addictive disorders. To prepare for the assignment, you should review the learning resources provided and become familiar with the Comprehensive Psychiatric Evaluation template. You should also identify a video case study to use for the assignment, view the assigned video case, and review the additional data provided in the “Case History Reports” document. You should consider what history would be necessary to collect from the patient and what interview questions would be needed to ask the patient. Finally, you should identify at least three possible differential diagnoses for the patient.
Steps to Consider in Writing the Assignment: Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders
To begin, review the Comprehensive Psychiatric Evaluation template provided below and familiarize yourself with the criteria for diagnosing substance-related and addictive disorders as outlined in the DSM-5. Select a video case study from the choices provided and review the patient’s case history report, paying attention to any cultural or contextual factors that may be relevant to the assessment and diagnosis process.

Next, consider what questions you would need to ask the patient during an interview to gather the necessary information for a comprehensive psychiatric evaluation. Take note of the patient’s chief complaint, symptomatology, and the duration and severity of their symptoms, as well as how their symptoms are impacting their daily functioning.

Based on your assessment, formulate at least three possible differential diagnoses, listed in order of priority, and provide supporting evidence for each diagnosis. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain how you ruled out each diagnosis to arrive at your primary diagnosis. Be sure to include pertinent positives and negatives that support your diagnosis, taking into consideration any cultural, social, or economic factors that may be relevant.

Finally, in your reflection notes, consider how you would approach the session differently if given the opportunity and discuss any legal or ethical considerations related to the patient’s treatment. Consider how you might incorporate health promotion and disease prevention strategies into your treatment plan, taking into account the patient’s age, ethnicity, and other risk factors.
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Comprehensive Psychiatric Evaluation Template
Patient Information:

Name: ___________ Date of Birth: ___________ Date of Evaluation: ___________

Identifying Data:

The patient is a _____-year-old (gender) (ethnicity) individual who presents with (chief complaint) and reports a history of (relevant medical and psychiatric history).

Reason for Referral:

The patient was referred for evaluation due to (reason for referral).

Subjective:

The patient reports experiencing (symptoms) for (duration). The symptoms have impacted the patient’s functioning in (specific areas of life).

Mental Status Examination:

Appearance:

Behavior:

Speech:

Mood:

Affect:

Thought Process:

Thought Content:

Perception:

Cognition:

Insight:

Judgment:

Assessment:

Based on the patient’s history and mental status examination, the following differential diagnoses are considered:

 	
(Differential Diagnosis 1) – (Supporting Evidence)
 	
(Differential Diagnosis 2) – (Supporting Evidence)
 	
(Differential Diagnosis 3) – (Supporting Evidence)

After considering the DSM-5 diagnostic criteria, (Differential Diagnosis #) can be ruled out because (reason). The critical-thinking process led to the primary diagnosis of (Primary Diagnosis).

Pertinent Positives:

Pertinent Negatives:

Plan:

The following plan is recommended for the patient:

 	
(Interventions)
 	
(Referrals)
 	
(Follow-up)

Reflection:

If I could conduct the session over, I would (reflection). In terms of legal/ethical considerations, (discussion). In terms of health promotion and disease prevention, (discussion).