lOMoAR cPSD| 67756003
Running header: Assessing and Diagnosing Patients with Substance-Related and Addictive
Disorders 1
Week 8 Assignment: Assessing and Diagnosing Patients with
Substance-Related and Addictive Disorders
(Video: Training Title 151)
College of Nursing - PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
October 23, 2022
Subjective:
CC (chief complaint): Substance use evaluation
, lOMoAR cPSD| 67756003
Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders 2
HPI: J.D. is a 47-year-old female who was referred for drug/substance use evaluation by her
family physician who was worried that some of other medications, drugs that she may use may
interact with the oxycodone. This was after the patient had asked him to prescribe oxycodone for
her elbow pain. Pt stated that she had requested for Oxycodone because “nothing else works”,
neither Ibuprofen nor Tylenol worked. She admits taking Tylenol three for a friend which she
tried but stated that she was “way allergic”, that she her face “flushed like real bad”, and that the
medication did not work. She admits trying morphine and codeine, and stated that it did not
work. Stated that she tried Dilaudid once in the ER but that it made her constipated, so much that
she had to go back to the hospital for constipation. She states that she also has headaches, and
has tried Demerol which worked for her headache, but did not do anything for her elbow. She
stated that Oxycontin is the only thing that works for both her headache and her elbow pain.
Other than medications she tried Yoga, meditation, which she stated works only while she was
doing them but does not help at all when she stopped. She states that she also tried warm, hot
compresses, with candles, long walks on the beach and massages from her boyfriend but it still
didn`t do anything for her elbow pain. She insists that she never takes anything else other than
Tylenol fish oil and vitamins. Stated that she drinks alcohol once to twice a week. She admits
having a legal problem from the drinking; was caught once for Driving Under the Influence of
alcohol (DUI). She admits using marijuana two to four times a week, or sometimes none; states
it relieves her headache. States that she has lost custody of her child due to her smoking
marijuana. Admits doing cocaine to relieve tension, last time was a month or two ago. She said
she has tried ecstasy twice and LSD once last year. Patient drinks a lot of coffee and smokes two
packs of cigarettes per day, with 20 mg Adderall. She stated that she has never had prescription
Running header: Assessing and Diagnosing Patients with Substance-Related and Addictive
Disorders 1
Week 8 Assignment: Assessing and Diagnosing Patients with
Substance-Related and Addictive Disorders
(Video: Training Title 151)
College of Nursing - PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
October 23, 2022
Subjective:
CC (chief complaint): Substance use evaluation
, lOMoAR cPSD| 67756003
Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders 2
HPI: J.D. is a 47-year-old female who was referred for drug/substance use evaluation by her
family physician who was worried that some of other medications, drugs that she may use may
interact with the oxycodone. This was after the patient had asked him to prescribe oxycodone for
her elbow pain. Pt stated that she had requested for Oxycodone because “nothing else works”,
neither Ibuprofen nor Tylenol worked. She admits taking Tylenol three for a friend which she
tried but stated that she was “way allergic”, that she her face “flushed like real bad”, and that the
medication did not work. She admits trying morphine and codeine, and stated that it did not
work. Stated that she tried Dilaudid once in the ER but that it made her constipated, so much that
she had to go back to the hospital for constipation. She states that she also has headaches, and
has tried Demerol which worked for her headache, but did not do anything for her elbow. She
stated that Oxycontin is the only thing that works for both her headache and her elbow pain.
Other than medications she tried Yoga, meditation, which she stated works only while she was
doing them but does not help at all when she stopped. She states that she also tried warm, hot
compresses, with candles, long walks on the beach and massages from her boyfriend but it still
didn`t do anything for her elbow pain. She insists that she never takes anything else other than
Tylenol fish oil and vitamins. Stated that she drinks alcohol once to twice a week. She admits
having a legal problem from the drinking; was caught once for Driving Under the Influence of
alcohol (DUI). She admits using marijuana two to four times a week, or sometimes none; states
it relieves her headache. States that she has lost custody of her child due to her smoking
marijuana. Admits doing cocaine to relieve tension, last time was a month or two ago. She said
she has tried ecstasy twice and LSD once last year. Patient drinks a lot of coffee and smokes two
packs of cigarettes per day, with 20 mg Adderall. She stated that she has never had prescription
