NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation
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Week #4: Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Dr. Suhad Sadik
Subjective:
CC (chief complaint): The patient is feeling anxious due to financial issues.
HPI: A 45-year-old male presents to the clinic for regular assessment. The patient has a history of depressive disorder and suicidal attempts through overdose. The patient reports having anxiety due to financial issues. The patient is currently responding well to the current medication.
Past Psychiatric History:
· General Statement: The patient had a history of depressive disorder and was hospitalized for a suicide attempt two months ago by overdose.
· Caregivers (if applicable): NA – Patient lives by himself.
· Hospitalizations: The patient was hospitalized two months ago for attempted suicide through overdose. Patient was in the hospital for eight days.
· Medication trials: The patient has not participated in medication trials.
· Psychotherapy or Previous Psychiatric Diagnosis: The patient does have a history of substance use in his early twenties: substance use, marijuana, and crack. The patient doesn’t use substances currently.
Substance Current Use and History: The patient does have a history of substance use in his early twenties. Substance use, marijuahna and crack. Patient doesn’t use substance currently.
Family Psychiatric/Substance Use History: The patient’s mother with a history of Bipolar Disorder. Unknown history of substance use in the family.
Psychosocial History: The patient is a 45-year-old Hispanic male, born and raised in Cuba, who moved to Miami at the age of 16. His higher level of education is high school. The patient was married once and had a daughter that lives out of the state with her mother. Currently patient lives by himself in a shared room. The patient is presently unemployed. His last job was as a UPS driver. He is receiving SSI, and unemployment. The patient is now looking for a job.
Medical History: The patient had been treated previously after a suicide attempt for overdose. The type of medication is not known.
· Current Medications: Patient was discharged from the hospital with Prozac 20 mg PO QAM and Zyprexa 10mg PO QHS.
· Allergies: The patient is allergic to Iodine.
· Reproductive Hx: The patient has a daughter but doesn’t have contact with her; she lives out of state.
ROS:
· GENERAL: Appears stated age, clothing is appropriated for the season, he is wearing a
blue polo shirt and khaki shorts with his shoes. He has a longish black hair. He wears glasses. Attention is good. He is able to focus on the conversation.
· HEENT: Visual and auditory functions intact, no visual loss, no hearing difficulties, no ear discomfort. No sinus infection. No history of LOC or neck or head injury. No history of seizures or tremors.
· SKIN: Skin is intact, no rash or itching. Skin has no wounds, lesions, or hyperpigmentation. There are no signs of self-harm.
· CARDIOVASCULAR: No chest pain or chest discomfort. No edema was noted. The patient denies heart palpitations.
· RESPIRATORY: No breathing difficulty. Patient denies SOB.
· GASTROINTESTINAL: Normal bowel movements, no abdominal pain.
· GENITOURINARY: Urinary frequency is normal
· MUSCULOSKELETAL: No muscle or back pain.
· LYMPHATICS: No inflammation of lymph nodes.
· ENDOCRINOLOGIC: No endocrine issues.
Objective:
Diagnostic results: The patients scores 13 on PHQ9, which shows moderate depression.
Assessment:
Mental Status Examination: The patient is alert and oriented to time, place, and situation. The patient is quite awake, attentive, and cooperative. The patient demonstrated good hygiene and dressed well for the event and weather. The speech is coherent but displays a depressed mood. His memory is intact and does not demonstrate any deficit. The patient reports being anxious due to his financial situation currently. The patient does not show evidence of mania, psychosis, or anxiety.
Differential Diagnoses:
Bipolar Disorder
The patient had a history of depressive moods, although he has demonstrated slight improvements. The patient also has a history of depressive disorder and is currently feeling anxious. Bipolar is associated with changing moods, which the patient has reported to have improved over the week. The patient is also said to have attempted suicide, which is common for patients with bipolar illness (Miller & Black, 2020).
Attention Deficit Disorder
The disorder commonly known as ADHD is a neurodevelopmental disorder and primarily affects the youths but can manifest even in adults. Some of the significant symptoms of the condition include aggression, repetition of actions, and generally poor concentration (Ewe, 2019). The patient demonstrates decreased attention, as demonstrated in the case that his attention was average, which means he was not attentive as it would have been required.
Wilson Disease
The condition is caused by the increased accumulation of copper in the brain and the eyes. The disease can be presented in the form of increased anxiety, mood swings, and the manifestation of depressive symptoms, which are evident in the patient (Aggarwal & Bhatt, 2018).
The patient is most likely to be assessed further for Bipolar disorder.
Reflections:
One thing I would do differently is to include the patient’s medication history. The patient has been hospitalized due to a medication overdose, but the type of medication was not included in the patient medical history during an evaluation. One consideration I would make during psychiatric therapy for patients with mental disorders is the impact of poverty and the inability to access quality mental health services. As a future mental health practitioner, it is essential to focus on mental health awareness in poverty-stricken regions to foster their ability to access mental health assessments and overall mental health awareness. It is crucial to carry out mental health education campaigns to ensure they understand the importance of mental health. Reaching out to rural communities and education promotes mental health awareness and reduces disparities in mental health access (Healthy People 2030). Psychological disorders require counseling therapy more than medical therapy. However, medication is essential because it helps a patient recover from their conditions, but the patient can have compliance issues that affect the overall effectiveness of the ordered therapy. Medication is the best treatment for mood disorders, but non-compliance may not serve any good for the client. The patient requires interdisciplinary therapy because of his previous treatment and the manifestation of mixed symptoms of depressive and mood disorders (McKee et al., 2018). However, some critical details that could have helped make more informed treatment decisions, like availing the patient’s social life, are lacking. Social life and conduct demonstrate the mental status of a patient. This would help understand the issue, which is instrumental in a therapeutic process.
Case Formulation and Treatment Plan:
The patient must be educated on avoiding triggering factors such as alcohol and drug use. Moreover, the patient can also be advised to eat a balanced diet and engage in exercise activities. This would help the patient fight depressive moods that might eventually escalate to a more severe condition (Antony & Barlow, 2020).
The patient should be educated on detecting early signs of depression and which strategies they should adopt once they discover mood changes. The patient may also be advised to take note of their depressive moods to ensure they are doing well and identify any changes that may be occurring (Antony & Barlow, 2020). This can be done effectively by having a journal entry to record their experiences.
The patient should also be taught on the values of self-worth and coping strategies they need to adopt to improve their self-esteem to avoid developing anxiety over things they have or do not have control over (Antony & Barlow, 2020). This will help prevent undue stigma and eventually achieve better results.
Treatment and Management
Medication is the primary treatment for bipolar disorder. The patient can be recommended for medication to modify and stabilize their moods. Mood stabilizers ensure the symptoms are kept under control and ensure extremes of the bipolar disease are managed. In the case of ADHD. The patient can be ordered for stimulants, while the anxiety symptoms can be treated using SSRIs and antidepressants (Antony & Barlow, 2020).
The patient is more recommended for psychotherapeutic treatment. The most appropriate therapy is cognitive-behavioral therapy (CBT) in the treatment of related mental illness, which includes anxiety and bipolar (Antony & Barlow, 2020). The patient needs to learn how to handle experiences that are not appealing or are causing fear, such as financial uncertainties. The patient needs to be educated on how he should handle his moods and manage stress with the assistance of a therapist.
The patient should be educated on handling symptoms associated with the disease. This will help avoid complications associated with the disease. The patient can be taught to identify common symptoms associated with bipolar disorder and how they should handle such symptoms to prevent the disease-causing serious complications (Antony & Barlow, 2020).
The patient should also be educated on how to manage their lifestyle to manage their moods. They can be taught the importance of having a good and regular sleep, avoiding alcohol and drugs, eating a good diet, exercising regularly, and overall maintenance of personal wellbeing.
The patient also needs to have a reliable source of support. Mental conditions have devastating experiences, and providing a patient with a support network maintains their motivation. The patient is allowed to share their experiences and also get the education and advice from people that might have experienced similar challenges in their lives (Antony & Barlow, 2020). The patient needs to know he is not a burden to people around him and can always rely on them for support.