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Week 8 _ Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Training Title 151

Name: Katarina Bykov

Gender: female

Age:41 years old

T- 97.4 P- 74 R 120 100/70 Ht 5’8 Wt 117lbs

Background: Moved to Washington State from Russia with her parents when she was 12 years

old. She has 2 brothers, 2 sisters. Denied family mental health or substance use issues. No

history of inpatient detox or rehab denied self-harm hx; Menses regular. Has chronic pain

issues. She works part time cashier at Aldi Grocery Store. Dropped out of high school in 11th

grade. Sleeps 4–9 hours on average, appetite good.

Symptom Media. (Producer). (2018). Training title 151 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-151




>> I see in your chart that you asked your family physician to prescribe oxycodone for your elbow pain,

and that your family physician is worried that some of other medications, drugs you may use may interact with the oxycodone?


>> Oxycodone is that’s the same as OxyContin?


>> Yeah. Oxycodone is the generic name.


>> Yeah, I did ask for OxyContin, but I don’t take any other medications or drugs.

I’m opposed to putting anything unhealthy in my body.


>> Okay. What else have you tried?


>> Nothing else works.


>> Ibuprofen, acetaminophen?


>> Not even close.


>> No?


>> Yeah. I mean,


I’m allergic to codeine.


>> Allergic?


>> Yeah, like in Tylenol three.

A little while back, my friend was in a motorcycle accident and had some leftover, and I tried one of those, and I was way allergic.


>> What was the allergic response you had?


>> My face flushed like real bad, besides it didn’t work.


>> Have you tried morphine?


>> Well, that’s addictive, isn’t it?


>> Yeah, well all the pain medications or most of them are addictive.


Anti-inflammatory medications are not usually addictive.


>> Yeah, I tried morphine and the codeine, didn’t work.


>> Okay.


>> Yeah, I get headaches too, so ideally I need something that works for both.

I’d rather not take two medications if I don’t have to.

Less medications the better, that’s what grandma always said.


>> Grandma? Okay.


>> Yeah.


>> Have you ever tried Dilaudid?


>> Yeah. They gave that to me in the ER once, but just made me dizzy and constipated.

Constipated for like a month.


>> Oh, wow.


>> I almost had to go back to the hospital for constipation.

Can you imagine having to go to the hospital for constipation?


>> Oh my goodness.


>> Yeah, that’s how bad it was.


>> Have you tried Demerol?


>> Yeah, it kind of worked for my headache.

It comes in a shot, right?


>> Yeah. An injection.


>> Yeah, they gave that to me at the hospital.

But that’s the thing, you can only get it at the hospital, so it’s not like it’s going to work for me everyday. It didn’t do anything for my elbow.

OxyContin it’s the only thing that works for both. The only thing that works for both.


>> You do seem set on the oxycodone?


>> Because it works.


>> What else have you tried other than medications?


>> Other than medications?


>> Yeah.


>> Yoga.


>> Okay.


>> Yeah. Tried that. Other kinds of meditation. I mean, that’s the thing with meditation is, it works while you’re doing it, but then as soon as you stop, zilch. Biofeedback.


>> Good.


>> One doc tried that, same thing. Works while you’re doing it, but then when you stop doesn’t help at all. What else?


Like warm, hot compresses, candles, long walks on the beach, massages.


>> Wow.


>> My boyfriend is really good at massages actually. He’s studied with this guru in India.

>> Oh, wow. Yeah, swear to God


>> You have tried a lot of solutions.


Let me ask you more about your medication history.


> I only take stuff for my headache and my elbow.


>> Okay.


>> Like I said, I don’t like putting unhealthy things in my body.


Vitamins, I take vitamins.


>> Yeah? Okay.


>> Like fish oils, some supplements, but nothing corporate, nothing pharmaceutical.

I don’t want to put that in me. Even coming here today, asking for this, it goes against my values.


>> I see. Okay.


>> But I got to function.


>> Do you drink alcohol?


>> On special occasions like weddings, funerals, birthdays.

I got a ton of friends, so whenever we have a birthday we’re going to drink.

Let me think, like holidays, New Years, and Christmases.

There’s Christmas and then we also celebrate Russian Orthodox Christmas on January 7th.


>> How often on the average?


>> When you add it all up, once, maybe twice a week, I guess.


>> Will you drink enough to get intoxicated?


>> Depends on who I’m drinking with. As Zane, that’s my boyfriend, he drinks a lot, so

I drink a little more when I’m with him.


>> Any legal problems from the drinking?


>> Once. So dumb.

Yeah, just one little charge for drinking. I was the tiniest little bit over the limit.

So yeah, I got that and I had to take that course, that stupid, boring course.

But I learned my lesson. If you’re a little bit over the limit, stick to the back roads.


>> So you will still drive?


>> Well, yeah, but I’m super careful.


>> You think after you’ve been drinking, that’s an okay idea to drive?


>> It’s better than letting Zano drive.


>> Zano?


>> Zane, Zano, same person. Yeah. He doesn’t even have his license anymore.

Not that it stops him.


>> What about marijuana?


>> Do I use it?

>> Yeah.

>> Marijuana medically helps with my headaches, so yeah, I use it.

It’s my right. Yeah, it’s your right. It’s everybody’s right.


>> How often?


>> Not often. Two, four times a week, sometimes none.

It’s expensive. Then when you do get some, suddenly everybody is your best friend and you

got to share, you know how it is.


>> Do you ever grow marijuana?


>> I used to. But then we moved and it’s not legal in this backward state.

Where we live it’s pretty public, its not really private.


>> Do you ever have any side effects from using marijuana like memory problems?


>> I was born with memory problems, Doc, I don’t think it’s from the marijuana.


>> Any legal trouble with the marijuana?


>> Once. I mean, I’m super careful. But Zano, he went away for a year for selling

the tiniest little bit to an undercover cop, which is total entrapment, which is how I lost custody of Camper.


>> Camper?


>> My son.


>> Oh.


>> Yeah. He’s staying with my ex husband’s parents right now. They take good care of him.


>> How long have you been divorced?


>> Oh no, I never married that guy.


>> Oh.


>> No way I would marry that jerk.

No, I don’t know. It’s been like four years since I’ve even seen him. Something like that, four years.


>> What happened?


>> Lucas, my ex, he freaked out because he caught me doing just a few lines of coke,

but everybody was doing it back then.

Anyway, his mom found the mirror, and the razors, and Lucas said I had to quit.

For whatever I lied, and when he caught me, I know it was bad to lie about that, but I don’t know it’s in the past.

Water under the bridge. You live, you learn, you move on.


>> Right. Do you use cocaine now?


>> No, hardly ever. I don’t know, it’s been like a month maybe, or two months or something since I have.


>> Any legal problems from using cocaine?


>> No, we hardly ever do it.


>> Have you thought about stopping altogether?


>> I hardly ever do it. Hardly even counts. I don’t know, when I do it, It’s just to relieve tension or it’s this thing Zano and I do to bring each other closer together, but I could quit anytime I wanted, easy.


>> Does your boyfriend have children?


>> Yeah, he’s got two kids. Yeah, but we don’t see them much. His other with his ex.


>> Oh?


>> She’s a real snobby type. You know the type? It is a freaking tragedy because I see his two kids just going down that same path.

They’re just two little snobs. It’s a real shame. We’re not allowed to see them anymore though,

so I guess like what’s the difference?

She went to court and said we were unsuitable. Not suitable.

Says it all real nice in court, and then not so nice over the phone,

if you know what I mean? She’s a real bitch.


>> Any other drugs?


Ecstasy? LSD?


>> This is going to make me sound like I’m some 1970s hippy, druggo person.

I’ve tried ecstasy twice, just twice, and LSD once, last year.

That was a bad trip. I am not doing that again.


>> Anything else?


>> Like what?


>> Stimulants?


>> Like power drinks if I need to stay up?

>> Sure

> Caffeine, I drink a lot of coffee.

I don’t know if cigarettes, do they count as stimulants?


>> Yeah.


>> Yeah, I’m trying to cut back. Two packs a day.


>> Ritalin, Dexedrine?


>> Oh, stimulants?


>> Right


>> Oh, yeah. Not a lot. Like hardly ever.

I mean, if Zano and I are down for whatever reason, or sluggish from smoking pot, or just like if I need to get back up again.

Yeah, Adderall, just 20 helps.


>> Do you ever take prescription medications


that are not prescribed for you?


>> Well, are you kidding me?

Why would I do that? I told you I don’t like medications in the first place.


>> Klonopin, Ativan, Xanax?


>> Those?


>> Yeah. Yeah, if my anxiety is acting up,

if my meditation isn’t working? Yeah, a couple Xana bars, but not a lot.


>> How often would you estimate that is?


>> I don’t know. Two? I don’t know.

I need like a freaking calendar to keep up with

all your questions, Doc, God.


>> So in the past,


who prescribed the oxycodone for you?


>> No one yet. Zano he takes them because he’s got shoulder and back problems, and I tried one and it really works.

To be honest it works fantastic.


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Week 8 _ Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

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

An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.

For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background.

Assignment Instructions:

· Use the Comprehensive Psychiatric Evaluation Template (Attached) to complete this Assignment.

· Review the Comprehensive Psychiatric Evaluation Exemplar (Attached) to see an example of a completed evaluation document. 

· Select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. Video # 151 (See the transcript).

· Consider what history would be necessary to collect from this patient.

· Consider what interview questions you would need to ask this patient.


· Identify at least three possible differential diagnoses for the patient. 

· Complete and submit your Comprehensive Psychiatric Evaluation (attached), including your differential diagnosis and critical-thinking process to formulate a primary 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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.).

· Minimums 5 references

Week 8 _ Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar


If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template
the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

· Chief complaint

· History of present illness (HPI)

· Past psychiatric history

· Medication trials and current medications

· Psychotherapy or previous psychiatric diagnosis

· Pertinent substance use, family psychiatric/substance use, social, and medical history

· Allergies


· Read rating descriptions to see the grading standards!

In the Objective section, provide:

· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.

· Read rating descriptions to see the grading standards!

In the Assessment section, provide:

· Results of the mental status examination,
presented in paragraph form.

· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 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


· Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. 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.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)


CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.


P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level


Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

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: Burning on urination, urgency, hesitancy, odor, odd color

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 polydipsia.

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).



Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. 

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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Week 8 _ Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date


CC (chief complaint):


Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:















Physical exam: if applicable

Diagnostic results:


Mental Status Examination:

Differential Diagnoses:



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