Assessing And Diagnosing Patients With Substance

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.

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.

To Prepare:

Review this week’s Learning Resources and consider the insights they provide.

Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.

View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.

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, including your differential diagnosis and critical-thinking process to formulate 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.).

 

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

CC Requesting for painkiller for elbow pain

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

 

Search transcript

00:00:15

>> I see in your chart that you asked

00:00:15

your family physician to

00:00:20

prescribe oxycodone for your elbow pain,

00:00:20

and that your family physician

00:00:25

is worried that some of other medications,

00:00:30

drugs you may use may interact with the oxycodone?

00:00:35

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

00:00:35

>> Yeah. Oxycodone is the generic name.

00:00:40

>> Yeah, I did ask for OxyContin,

00:00:45

but I don’t take any other medications or drugs.

00:00:50

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

00:00:55

>> Okay. What else have you tried?

00:01:00

>> Nothing else works.

00:01:00

>> Ibuprofen, acetaminophen?

00:01:00

>> Not even close.

00:01:05

>> No?

00:01:05

>> Yeah. I mean,

00:01:05

I’m allergic to codeine.

00:01:05

>> Allergic?

00:01:05

>> Yeah, like in Tylenol three.

00:01:10

A little while back, my friend

00:01:10

was in a motorcycle accident and had some leftover,

00:01:15

and I tried one of those,

00:01:15

and I was way allergic.

00:01:20

>> What was the allergic response you had?

00:01:25

>> My face flushed like real bad,

00:01:25

besides it didn’t work.

00:01:30

>> Have you tried morphine?

00:01:30

>> Well, that’s addictive, isn’t it?

00:01:35

>> Yeah, well all the pain medications

00:01:35

or most of them are addictive.

00:01:35

Anti-inflammatory medications are not usually addictive.

00:01:45

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

00:01:50

>> Okay.

00:01:50

>> Yeah, I get headaches too,

 

00:01:55

so ideally I need something that works for both.

00:02:00

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

00:02:05

Less medications the better,

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that’s what grandma always said.

00:02:05

>> Grandma? Okay.

00:02:05

>> Yeah.

00:02:10

>> Have you ever tried Dilaudid?

00:02:10

>> Yeah. They gave that to me in the ER once,

00:02:15

but just made me dizzy and constipated.

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Constipated for like a month.

00:02:25

>> Oh, wow.

00:02:25

>> I almost had to go back to

00:02:25

the hospital for constipation.

00:02:25

Can you imagine having to go to

 

00:02:25

the hospital for constipation?

00:02:30

>> Oh my goodness.

00:02:30

>> Yeah, that’s how bad it was.

00:02:30

>> Have you tried Demerol?

00:02:35

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

00:02:40

It comes in a shot, right?

00:02:40

>> Yeah. An injection.

00:02:45

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

00:02:45

But that’s the thing, you

00:02:50

can only get it at the hospital,

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so it’s not like it’s going to work for me everyday.

00:02:55

It didn’t do anything for my elbow.

00:02:55

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

00:03:00

The only thing that works for both.

 

00:03:00

>> You do seem set on the oxycodone?

00:03:00

>> Because it works.

00:03:05

>> What else have you tried other than medications?

00:03:10

>> Other than medications?

00:03:10

>> Yeah.

00:03:10

>> Yoga.

00:03:10

>> Okay.

00:03:10

>> Yeah. Tried that. Other kinds of meditation.

00:03:20

I mean, that’s the thing with meditation is,

00:03:20

it works while you’re doing it,

00:03:25

but then as soon as you stop, zilch. Biofeedback.

00:03:30

>> Good.

00:03:30

>> One doc tried that, same thing.

00:03:30

Works while you’re doing it,

 

00:03:35

but then when you stop doesn’t help at all. What else?

00:03:40

Like warm, hot compresses,

00:03:45

candles, long walks on the beach, massages.

00:03:50

>> Wow.

00:03:50

>> My boyfriend is really good at massages actually.

00:03:55

He’s studied with this guru in India.

00:03:55

> Oh, wow.

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>> Yeah, swear to God

00:04:00

>> You have tried a lot of solutions.

00:04:00

Let me ask you more about your medication history.

00:04:05

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

00:04:10

>> Okay.

00:04:15

>> Like I said, I don’t like

00:04:15

putting unhealthy things in my body.

 

00:04:15

Vitamins, I take vitamins.

00:04:20

>> Yeah? Okay.

00:04:20

>> Like fish oils, some supplements,

00:04:20

but nothing corporate, nothing pharmaceutical.

00:04:25

I don’t want to put that in me.

00:04:30

Even coming here today,

00:04:35

asking for this, it goes against my values.

00:04:35

>> I see. Okay.

00:04:35

>> But I got to function.

00:04:40

>> Do you drink alcohol?

00:04:40

>> On special occasions

00:04:45

like weddings, funerals, birthdays.

00:04:50

I got a ton of friends, so

00:04:50

whenever we have a birthday we’re going to drink.

 

00:04:55

Let me think, like holidays,

00:04:55

New Years, and Christmases.

00:05:00

There’s Christmas and then we also celebrate

00:05:05

Russian Orthodox Christmas on January 7th.

00:05:10

>> How often on the average?

00:05:15

>> When you add it all up,

00:05:15

once, maybe twice a week, I guess.

00:05:20

>> Will you drink enough to get intoxicated?

00:05:20

>> Depends on who I’m drinking with.

00:05:25

As Zane, that’s my boyfriend,

00:05:30

he drinks a lot, so

00:05:30

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

00:05:30

>> Any legal problems from the drinking?

00:05:35

>> Once. So dumb.

 

00:05:40

Yeah, just one little charge for drinking.

00:05:45

I was the tiniest little bit over the limit.

00:05:45

So yeah, I got that and I had to take that course,

00:05:50

that stupid, boring course.

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But I learned my lesson. If you’re

00:05:55

a little bit over the limit,

00:05:55

stick to the back roads.

00:05:55

>> So you will still drive?

00:06:00

>> Well, yeah, but I’m super careful.

00:06:00

>> You think after you’ve been drinking,

00:06:05

that’s an okay idea to drive?

00:06:05

>> It’s better than letting Zano drive.

00:06:10

>> Zano?

00:06:10

>> Zane, Zano, same person.

00:06:15

Yeah. He doesn’t even have his license anymore.

00:06:15

Not that it stops him.

00:06:20

>> What about marijuana?

00:06:20

>> Do I use it?

00:06:25

>> Yeah.

00:06:25

>> Marijuana medically helps with my headaches,

00:06:30

so yeah, I use it.

00:06:35

It’s my right. Yeah, it’s

00:06:35

your right. It’s everybody’s right.

00:06:40

>> How often?

00:06:40

>> Not often.

00:06:45

Two, four times a week, sometimes none.

00:06:50

It’s expensive. Then when you do get some,

00:06:55

suddenly everybody is your best friend and you

00:06:55

got to share, you know how it is.

00:06:55

>> Do you ever grow marijuana?

00:07:00

>> I used to. But then we

00:07:05

moved and it’s not legal in this backward state.

00:07:05

Where we live it’s pretty public,

00:07:10

its not really private.

00:07:10

>> Do you ever have any side effects

00:07:15

from using marijuana like memory problems?

00:07:15

>> I was born with memory problems,

00:07:20

Doc, I don’t think it’s from the marijuana.

00:07:20

>> Any legal trouble with the marijuana?

00:07:25

>> Once. I mean, I’m super careful.

00:07:30

But Zano, he went away for

00:07:30

a year for selling

00:07:35

the tiniest little bit to an undercover cop,

 

00:07:35

which is total entrapment,

00:07:40

which is how I lost custody of Camper.

00:07:40

>> Camper?

00:07:45

>> My son.

00:07:45

>> Oh.

00:07:45

>> Yeah. He’s staying with

00:07:45

my ex husband’s parents right now.

00:07:50

They take good care of him.

00:07:50

>> How long have you been divorced?

00:07:55

>> Oh no, I never married that guy.

00:07:55

>> Oh.

00:07:55

>> No way I would marry that jerk.

00:08:00

No, I don’t know.

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It’s been like four years since I’ve even seen him.

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Something like that, four years.

00:08:05

>> What happened?

00:08:10

>> Lucas, my ex,

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he freaked out because he caught

00:08:15

me doing just a few lines of coke,

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but everybody was doing it back then.

00:08:20

Anyway, his mom found the mirror,

00:08:25

and the razors, and Lucas said I had to quit.

00:08:30

For whatever I lied,

00:08:35

and when he caught me,

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I know it was bad to lie about that,

00:08:40

but I don’t know it’s in the past.

00:08:45

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

00:08:45

>> Right. Do you use cocaine now?

 

00:08:50

>> No, hardly ever.

00:08:55

I don’t know, it’s been like a month maybe,

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or two months or something since I have.

00:08:55

>> Any legal problems from using cocaine?

00:09:05

>> No, we hardly ever do it.

00:09:10

>> Have you thought about stopping altogether?

00:09:15

>> I hardly ever do it.

00:09:15

Hardly even counts.

00:09:20

I don’t know, when I do it,

00:09:20

it’s just to relieve tension

00:09:20

or it’s this thing Zano

00:09:25

and I do to bring each other closer together,

00:09:30

but I could quit anytime I wanted, easy.

00:09:35

>> Does your boyfriend have children?

 

00:09:35

>> Yeah, he’s got two kids.

00:09:40

Yeah, but we don’t see them much.

00:09:45

His other with his ex.

00:09:45

>> Oh?

00:09:50

>> She’s a real snobby type. You know the type?

00:09:50

It is a freaking tragedy

00:09:55

because I see his two kids

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just going down that same path.

00:10:00

They’re just two little snobs.

00:10:00

It’s a real shame.

00:10:05

We’re not allowed to see them anymore though,

00:10:10

so I guess like what’s the difference?

00:10:10

She went to court and said we were unsuitable.

00:10:15

Not suitable.

 

00:10:20

Says it all real nice in court,

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and then not so nice over the phone,

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if you know what I mean?

00:10:25

She’s a real bitch.

00:10:25

>> Any other drugs?

00:10:25

Ecstasy? LSD?

00:10:35

>> This is going to make me sound like I’m

00:10:35

some 1970s hippy, druggo person.

00:10:40

I’ve tried ecstasy twice,

00:10:45

just twice, and LSD once, last year.

00:10:50

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

00:10:55

>> Anything else?

00:10:55

>> Like what?

00:11:00

>> Stimulants?

 

00:11:00

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

00:11:05

>> Sure

00:11:05

>> Caffeine, I drink a lot of coffee.

00:11:10

I don’t know if cigarettes,

00:11:10

do they count as stimulants?

00:11:10

>> Yeah.

00:11:10

>> Yeah, I’m trying to cut back.

00:11:15

Two packs a day.

00:11:15

>> Ritalin, Dexedrine?

00:11:20

>> Oh, stimulants?

00:11:20

>> Right

00:11:20

>> Oh, yeah. Not a lot.

00:11:25

Like hardly ever.

00:11:25

I mean, if Zano and I are down for whatever reason,

 

00:11:30

or sluggish from smoking pot,

00:11:35

or just like if I need to get back up again.

00:11:35

Yeah, Adderall, just 20 helps.

00:11:40

>> Do you ever take prescription medications

00:11:40

that are not prescribed for you?

00:11:45

>> Well, are you kidding me?

00:11:45

Why would I do that?

00:11:50

I told you I don’t like medications in the first place.

00:11:50

>> Klonopin, Ativan, Xanax?

00:11:55

>> Those?

00:11:55

>> Yeah.

00:12:00

>> Yeah, if my anxiety is acting up,

00:12:05

if my meditation isn’t working?

00:12:10

Yeah, a couple Xana bars,

00:12:10

but not a lot.

00:12:10

>> How often would you estimate that is?

00:12:15

>> I don’t know.

00:12:20

Two? I don’t know.

00:12:20

I need like a freaking calendar to keep up with

00:12:25

all your questions, Doc, God.

00:12:25

>> So in the past,

00:12:30

who prescribed the oxycodone for you?

00:12:30

>> No one yet. Zano he

00:12:35

takes them because he’s got shoulder and back problems,

00:12:40

and I tried one and it really works.

00:12:45

To be honest it works fantastic.

00:12:45

This transcript was automatically generated using speech recognition technology. Because this method relies on machine learning algorithms, the quality of transcripts may vary. To request this transcript be improved with enhanced accuracy, please email transcripts@alexanderstreet.com.

 

About “Training Title 151”

In Test Section Index, Episode 151 (Santa Monica, CA: Symptom Media, 2018), 13 minutes

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