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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 fo

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:



© 2021 Walden University Page 1 of 3

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 demonstrat

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].




>> 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 rathe