Psychopathology Diagnostic Reasoning

 

 

Age: 33 years old
T- 100.0 P- 108 R 20 180/110 Ht 5’6 Wt 146lbs
Background: Lisa is in a Naples, FL detox facility thinking about long term rehab. She is
considering treatment for her Hep C+ but needs to get clean first. She has been abusing opiates,
approximately $100 daily. She admits to cannabis 1-2 times weekly (“I have a medical card”),
and 1/2 gallon of vodka daily. She has past drug paraphernalia possession arrest. Her admission
labs. abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS
positive for opiates, THC. Positive for alcohol or other drugs. BAL .308; other labs within
normal ranges. She reports sexual abuse as child ages 6-9 perpetrator being her father who went
to prison for the abuse and drug charges. She is estranged from him. Mother lives in Maine, hx
of agoraphobia and benzodiazepine abuse. Older brother has not contact with family in last 10
years, hx of opioid use. Sleeps 5-6 hrs., appetite decreased, prefers to get high instead of eating.
Allergies: azithromycin

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-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.)

Sample Solution

Comprehensive Psychiatric Evaluation for Lisa

Subjective

Chief Complaint: Lisa is considering long-term rehabilitation for opiate dependence and treatment for Hepatitis C (HCV).

Symptomology:

  • Opiate abuse: Daily use for an unspecified duration, spending ~$100/day.
  • Alcohol abuse: Consumes 1/2 gallon of vodka daily.
  • Cannabis use: 1-2 times weekly (reports having a medical card).
  • Sleep problems: Sleeps 5-6 hours nightly.
  • Decreased appetite: Prioritizes getting high over eating.
  • History of childhood sexual abuse (ages 6-9) by father (incarcerated for abuse and drug charges).
  • Family history:
    • Mother: Agoraphobia and benzodiazepine abuse.
    • Brother: Opioid use disorder, estranged from family.

Impact on Functioning:

  • Legal: Past arrest for drug paraphernalia possession.
  • Physical health: Abnormal liver function tests suggestive of potential liver damage from chronic alcohol and substance abuse.
  • Social:** Strained family relationships.

Objective

  • Vital Signs: T 100.0 F, P 108, R 20, BP 180/110 mmHg
  • Height: 5’6″
  • Weight: 146 lbs

Assessment

Mental Status Examination (MSE):

A formal MSE was not documented; however, based on the information provided, the following can be noted:

  • Mood: Not documented, but likely depressed given anhedonia (loss of interest in pleasurable activities) and decreased appetite.
  • Affect: Not documented.
  • Thought Process: Not documented.
  • Thought Content: No reports of suicidal or homicidal ideation.
  • Perception: No reports of hallucinations or delusions.
  • Sensorium: Alert and oriented to person, place, and time.
  • Insight and Judgment: Poor insight into the severity of her substance abuse and its impact on her health. Judgment is impaired due to active substance use.

Differential Diagnosis:

  1. Opioid Use Disorder, Severe (primary diagnosis):
    • Meets criteria for severe Opioid Use Disorder based on daily use for an unspecified duration, spending significant amounts of money to obtain opioids, and neglecting basic needs (eating) to use.
  2. Alcohol Use Disorder, Severe:
    • Meets criteria for severe Alcohol Use Disorder based on daily consumption of large quantities of alcohol and potential health consequences (elevated liver enzymes).
  3. Post-Traumatic Stress Disorder (PTSD):
    • History of childhood sexual abuse is a significant risk factor for PTSD. However, without further information on symptoms (e.g., flashbacks, nightmares, hypervigilance), it cannot be definitively diagnosed at this time.

Justification for Primary Diagnosis:

Opioid Use Disorder is the most likely primary diagnosis due to the following:

  • Pertinent Positives: Daily opiate use, spending significant amounts of money to obtain opioids, neglecting basic needs to use.
  • Pertinent Negatives: No significant history of other substance use besides alcohol and cannabis (cannabis use appears less problematic in the context of daily opiate and alcohol use).

Critical Thinking Process:

The decision to prioritize Opioid Use Disorder as the primary diagnosis is based on the severity of her opiate use and its impact on her life. While alcohol abuse is also significant, addressing the opioid dependence is essential for her overall health and ability to engage in treatment for HCV. Additionally, addressing the trauma from her childhood sexual abuse can be incorporated into her treatment plan once she achieves sobriety.

Reflection Notes

  • Additional Information: A more comprehensive MSE would be helpful to further assess her mental status and rule out other potential diagnoses (e.g., Major Depressive Disorder). Additionally, exploring her motivations for seeking treatment and potential barriers to recovery would be crucial for treatment planning.
  • Legal/Ethical Considerations: It is important to obtain informed consent for treatment, including disclosure of the diagnosis and treatment plan. Additionally, mandatory reporting laws may apply depending on the jurisdiction and her past child sexual abuse. Consulting with a supervisor or legal professional might be necessary to ensure all legal and ethical obligations are met.
  • Health Promotion and Disease Prevention: Education regarding the risks of continued substance use on her physical and mental health, as well as the potential for HCV transmission, is crucial. Connecting her with resources for harm reduction (e.g., naloxone) and infectious disease management (HCV treatment) is essential.
  • Social Support: Encouraging her to reconnect with supportive family members (if possible) or explore support groups can be beneficial for her recovery.
  • Cultural Considerations: While not explicitly

 

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