lOMoAR cPSD| 66549320
1
Complete Psychiatric Evaluation
Master of Science in Nursing, Walden University
NRNP-6635-15: Psychopathology and Diagnostic Reasoning
2024
Comprehensive Psychiatric Evaluation
Substance and addictive disorders encompass the misuse of several classes of drugs such
as alcohol, cannabis, opioids, caffeine, stimulants, sedatives, hypnotics, etc. These drugs activate
the brain’s reward system making the user neglect other duties and activities of their lives in
favor of taking the drug to continue experiencing those feelings. These disorders can lead to
physical, mental, social, academic, and occupational impairment. Stevens et al. (2019)
emphasized on the complexity of diagnosing psychiatric disorders in the context of drug abuse
and advised, a careful and detailed chronological history of symptom development and its
relationship to the substance abuse is critical to clarifying diagnoses.
The purpose of this paper is to conduct a comprehensive psychiatric evaluation of a
patient suffering from substance-related and addictive disorders and provide differential
, lOMoAR cPSD| 66549320
2
diagnoses based on DSM-V criteria and through evidence-based rationale. The paper will also
discuss legal and ethical aspects, social determinants of health, as well as health promotion and
disease prevention strategies when evaluating such patient populations.
Subjective
(Training Title 82)
CC: “I’m scared people are going to think I am an addict, because I am not”
HPI: LT is a 33-year-old Caucasian female who presents here today for detox, with plans to
transition to long-term rehab for substance abuse. However, she expresses concerns about people
stigmatizing her as an addict and potentially losing her business because “I am not an addict.”
She admits to using opioids daily and spends $100 a day just on opioids (for the last 14 months),
uses cannabis 1-2 times a week (for the last 24 months), and states she has a “medical card” for
this use. She also endorses drinking half a gallon of vodka daily for the last 14 months. She has
been smoking crack with her boyfriend (started 4 months ago, smokes crack daily) and describes
the feeling with excitement “it hits me so well”, however, denies being an addict. She is more
concerned about other people finding out and losing her business. She was arrested due to
paraphernalia possession two years ago. Sleeps 5-6 hrs per night. She has a poor appetite as she
prefers to “get high” instead of eating. She was diagnosed with Hep-C 6 months ago and plans
on seeking treatment for this.
Past Psychiatric History: denies any past psychiatric history, and denies previous diagnoses of
mental disorders such as MDD, anxiety, PTSD, and schizophrenia.
General Statement: LT denies any history of hospitalization for a medical or psychiatric
condition previously, denies psychotherapy, denies hx of relapse.
Caregivers: LT presents here today, unaccompanied, voluntarily.
1
Complete Psychiatric Evaluation
Master of Science in Nursing, Walden University
NRNP-6635-15: Psychopathology and Diagnostic Reasoning
2024
Comprehensive Psychiatric Evaluation
Substance and addictive disorders encompass the misuse of several classes of drugs such
as alcohol, cannabis, opioids, caffeine, stimulants, sedatives, hypnotics, etc. These drugs activate
the brain’s reward system making the user neglect other duties and activities of their lives in
favor of taking the drug to continue experiencing those feelings. These disorders can lead to
physical, mental, social, academic, and occupational impairment. Stevens et al. (2019)
emphasized on the complexity of diagnosing psychiatric disorders in the context of drug abuse
and advised, a careful and detailed chronological history of symptom development and its
relationship to the substance abuse is critical to clarifying diagnoses.
The purpose of this paper is to conduct a comprehensive psychiatric evaluation of a
patient suffering from substance-related and addictive disorders and provide differential
, lOMoAR cPSD| 66549320
2
diagnoses based on DSM-V criteria and through evidence-based rationale. The paper will also
discuss legal and ethical aspects, social determinants of health, as well as health promotion and
disease prevention strategies when evaluating such patient populations.
Subjective
(Training Title 82)
CC: “I’m scared people are going to think I am an addict, because I am not”
HPI: LT is a 33-year-old Caucasian female who presents here today for detox, with plans to
transition to long-term rehab for substance abuse. However, she expresses concerns about people
stigmatizing her as an addict and potentially losing her business because “I am not an addict.”
She admits to using opioids daily and spends $100 a day just on opioids (for the last 14 months),
uses cannabis 1-2 times a week (for the last 24 months), and states she has a “medical card” for
this use. She also endorses drinking half a gallon of vodka daily for the last 14 months. She has
been smoking crack with her boyfriend (started 4 months ago, smokes crack daily) and describes
the feeling with excitement “it hits me so well”, however, denies being an addict. She is more
concerned about other people finding out and losing her business. She was arrested due to
paraphernalia possession two years ago. Sleeps 5-6 hrs per night. She has a poor appetite as she
prefers to “get high” instead of eating. She was diagnosed with Hep-C 6 months ago and plans
on seeking treatment for this.
Past Psychiatric History: denies any past psychiatric history, and denies previous diagnoses of
mental disorders such as MDD, anxiety, PTSD, and schizophrenia.
General Statement: LT denies any history of hospitalization for a medical or psychiatric
condition previously, denies psychotherapy, denies hx of relapse.
Caregivers: LT presents here today, unaccompanied, voluntarily.
