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

 

Patient Name: John Doe

Age: 32

Gender: Male

Date of Evaluation: 03/13/2023

Identifying Information

The patient is a 32-year-old male who was brought in for evaluation by his wife due to his recent drug use and erratic behavior. He is currently unemployed and lives with his wife and two children.

Chief Complaint

The patient’s chief complaint is “I can’t stop using drugs.”

History of Present Illness

The patient reports that he has been using heroin for the past year, and he has been experiencing intense cravings and withdrawal symptoms when he tries to quit. He reports that he uses the drug to alleviate anxiety and depression symptoms. He also reports that he has been experiencing decreased energy, sleep disturbances, and appetite changes.

Mental Status Examination

The patient was cooperative and communicative during the evaluation. His mood was depressed, and his affect was constricted. His thought processes were tangential, and he had difficulty with concentration and memory. He denied suicidal or homicidal ideation.

Diagnostic Impressions

 	
Substance Use Disorder
 	
Major Depressive Disorder
 	
Generalized Anxiety Disorder

Assessment

The patient’s substance use disorder is the primary diagnosis. The DSM-5 criteria for substance use disorders include the presence of impaired control, social impairment, risky use, and pharmacological criteria. The patient meets the criteria for severe opioid use disorder based on his intense cravings and withdrawal symptoms. He also meets the criteria for major depressive disorder due to his depressed mood, decreased energy, sleep disturbances, and appetite changes. Finally, he meets the criteria for generalized anxiety disorder based on his report of anxiety symptoms.

Differential Diagnosis

 	
Substance-induced mood disorder
 	
Bipolar disorder
 	
Adjustment disorder with mixed anxiety and depressed mood

The differential diagnoses were considered based on the patient’s depressive symptoms, but the DSM-5 criteria for each diagnosis were ruled out based on the patient’s history and current symptoms.

Critical-Thinking Process

The primary diagnosis of substance use disorder was selected based on the DSM-5 criteria and the patient’s history of heroin use, intense cravings, and withdrawal symptoms. The secondary diagnoses of major depressive disorder and generalized anxiety disorder were also made based on the patient’s reported symptoms.

Reflection Notes

If I could conduct the session over, I would spend more time discussing the patient’s social history and family dynamics to better understand his support system and potential sources of stress. Legal/ethical considerations include obtaining informed consent and ensuring patient confidentiality. Health promotion and disease prevention should take into account the patient’s age, gender, and cultural background. The patient’s past medical history and socioeconomic factors should also be considered when developing a treatment plan.