Substance-Related and Addictive Disorders
Substance-Related and Addictive Disorders
REQUIRED READING:
• Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
o Chapter 26, “Assessing Alcohol Use Disorder”
• MeditrekLinks to an external site.
https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.to an external site.
• Document: Focused SOAP Note Template (Word document)Download Focused SOAP Note Template (Word document)
• Document: Focused SOAP Note Exemplar (Word document)Download Focused SOAP Note Exemplar (Word document)
• Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.
o Chapter 15, “Alcohol-Related Disorders”
o Chapter 16, “Drug Addiction”
• Office of Disease Prevention and Health Promotion. (n.d.). Social Determinates of Health.Links to an external site. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health
RECOMMENDED READING:
• American Psychiatric Association. (2018). Practice guideline for the pharmacological treatment of patients with alcohol use disorderLinks to an external site.. https://psychiatryonline.org/doi/book/10.1176/appi.books.9781615371969
Links to an external site.
• American Society of Addiction Medicine. (2020). Clinical practice guidelines on alcohol withdrawal managementLinks to an external site.. https://www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf?sfvrsn=ba255c2_2
Links to an external site.
• American Society of Addiction Medicine. (2020). National practice guideline for the treatment of opioid use disorder: 2020 focused updateLinks to an external site.. http://eguideline.guidelinecentral.com/i/1224390-national-practice-guideline-for-the-treatment-of-opioid-use-disorder-2020-update/0Links to an external site.
• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
ASSIGNMENT
Select a child/adolescent or adult patient from your clinical experience who presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
• Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
• Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.
o 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?
o Objective: What observations did you make during the psychiatric assessment?
o Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
o Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
o Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
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