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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): ‘I am so anxious when around people.’

HPI: Kennedy is a 31-year-old male that has been admitted to the unit for treatment for the past 10 weeks due to alcohol, pcp, and marijuana abuse. The patient has a diagnosis of bipolar disorder and post-traumatic stress disorder and is currently undergoing treatment. The client reports that the accompanying symptoms when he is around people include stomach upset, sweating, and a racing heart. He also feels paranoid that people are talking about him and out to get him. As a result, he isolates himself. He also reports hearing voices that tell him to do bad things. He reports sleep problems that include nightmares. His energy levels are on and off. He also gets emotional outbursts and anger sometimes. He has thoughts of self-harm without a plan. His appetite changes since it is a time good and bad sometimes.

NRNP PRAC 6635 Comprehensive Psychiatric Evaluation Template
NRNP PRAC 6635 Comprehensive Psychiatric Evaluation Template

Past Psychiatric History:

  • General Statement: ‘I am so anxious when around people.’
  • Caregivers (if applicable): none
  • Hospitalizations: This is the first hospitalization. There are no other histories of hospitalizations for mental health problems.
  • Medication trials: None
  • Psychotherapy or Previous Psychiatric Diagnosis: No history of psychotherapy. He has previous diagnoses of bipolar disorder and post-traumatic stress disorder.

Substance Current Use and History: The client has a history of alcohol, pcp, and marijuana abuse. No current history of abuse was given.

Family Psychiatric/Substance Use History: The client reports that his mother’s side has a history of anxiety, depression, and substance abuse.

Psychosocial History: The client is single. He has a history of being picked up a lot and isolated when he was a child. He is not employed because of his disability. He is currently an unauthorized probation because of smacking someone in the door where he was locked up for 14 days.

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Medical History:

 

  • Current Medications: The patient is currently using Trazodone 150 mg, Prazosin 1 mg, Seroquel 50 mg, and Fluoxetine 40mg.
  • Allergies: No history of allergies
  • Reproductive Hx: No history of sexually transmitted infections, increased urinary urgency, and pain during urination

ROS:

GENERAL:  The patient appeared appropriately dressed for the occasion. Absent upper arm tremors, severe or abnormal weight loss.

HEAD/NECK: The client denied lymphadenopathy, neck pain, rigidity, distended veins, and pain in swallowing.

EYES: The client denied vision changes, drainage, pain, or double vision. He does not use corrective lenses.

EARS/NOSE/MOUTH/THROAT: The patient denied changes in hearing, ear drainage, ear pain, and infections. He also denied nasal congestion, drainage, and nose bleeds. He denied halitosis, difficulties in swallowing, bleeding gums, sore throat, and sore tongue.

CARDIOVASCULAR: The client denied chest pain and palpitations.

PULMONARY:  The client denied shortness of breath, cough, dyspnea, wheezing, and pleuritic pain.

GASTROINTESTINAL: He denied abdominal tenderness, constipation, diarrhea, and bloating.

GENITOURINARY: The client denied urinary incontinence, painful urination, increased frequency in urination, and abnormal smell of urine.

MUSCULOSKELETAL: The patient denied muscle pain, fractures, tenderness, and muscle weakness.

INTEGUMENTARY:  The client denied rashes, lumps, bruises, and lacerations.

NEUROLOGICAL:  He denied headache, dizziness, vomiting, and nausea. He experienced slurring of speech during the assessment.

PSYCHIATRIC: The client has a history of post-traumatic stress disorder and bipolar disorder.

ENDOCRINE: The client denied cold, heat intolerance, and changes in body weight as well as polyuria, polydipsia, and polyphagia.

HEMATOLOGIC/LYMPHATIC:  The patient denied lymphadenopathy.

ALLERGIC/IMMUNOLOGIC:  The client denied any history of food, drug, or environmental allergies.

Physical exam: if applicable

Diagnostic results: Diagnostic and laboratory investigations are essential to developing an accurate diagnosis for Kennedy. One of the recommended diagnostic investigations is thyroid function tests. Thyroid function tests are important to rule out thyroid disorders such as hyperthyroidism as the cause of symptoms that include lack of attention and insomnia. Blood tests should also be performed to rule out any infection. Tests such as complete blood count will enable the psychiatrists to initiate necessary treatments to treat any infection the patient might be having. There is also the need to perform diagnostic imaging of the brain to rule out pathologies such as tumors. The patient experiences symptoms such as increased agitation, emotional outbursts, and easy irritability, which may necessitate imaging studies to rule out any brain pathologies that may be contributing to the problem.

Assessment

Mental Status Examination: Kennedy appears appropriately dressed for the occasion. He is oriented to self, others, time, and events. He does not demonstrate abnormal movements such as tics and tremors. Kennedy reports a recent experience of anxiety attacks. He also reports a history of delusions and auditory hallucinations. The patient notes a history of suicidal thoughts without a plan. He does not have a history of a suicide attempts. The thought process is future-oriented.

Differential Diagnoses:

  1. Generalized anxiety disorder: The first primary diagnosis that should be considered for Kennedy is generalized anxiety disorder. Kennedy has symptoms that align with those associated with this disorder. According to DSMV, patients with generalized anxiety disorder experience symptoms that include excessive worry and anxiety about things. Excessive worry is often difficult for the patient to control. The accompanying symptoms of excessive worry and anxiety include restlessness, easy fatigability, impaired concentration, irritability, increased muscle aches, difficulty in sleeping, sweating, and palpitations (DeMartini et al., 2019). Kennedy has excessive worry and anxiety when with a group of people with some of the above accompanying symptoms, hence, generalized anxiety disorder is his primary diagnosis.
  2. Persecutory delusion: The other primary diagnosis that should be considered for Kennedy is persecutory delusion. Persecutory delusion is a mental health disorder characterized by the patient feeling that a person or a group of people want to hurt them. Patients believe that their perception is true despite lacking any proof. Persecutory delusion is common in patients diagnosed with post-traumatic stress disorder, schizophrenia, or schizoaffective disorder (Diaconescu et al., 2019). Kennedy has a history of being diagnosed with post-traumatic stress disorder. As a result, persecutory delusion should be considered as part of the primary diagnosis.
  3. Depression: The other secondary diagnosis to consider for Kennedy is depression. Depression is a mental disorder that is characterized by patients reporting depressed moods in almost all day, every day. The DSMV also asserts that patients with depression experience symptoms that include diminished interest or pleasure in activities most of the day almost every day, weight loss or gain, slowed thought process and physical activity, fatigue, feeling worthless, and difficulty in concentration. Patients also report recurrent suicidal thoughts, attempts, plans, and insomnia (Kraus et al., 2019). Kennedy has some of the symptoms associated with depression. He reports changes in his appetite, some experiences of lack of energy, and insomnia. Therefore, post-traumatic stress disorder is a secondary diagnosis that should be considered when developing a treatment plan.
  4. Post-traumatic stress disorder: The last differential diagnosis that should be considered for Kennedy is post-traumatic stress disorder. Post-traumatic stress disorder is diagnosed in patients having a history of direct or indirect traumatic experiences. Patients experience symptoms that include avoidance of any stimuli related to the trauma, flashbacks about the trauma, nightmares, and significant distress when exposed to the stimuli or trauma. Patients also experience additional symptoms that include the negative alterations in their cognition and mood-related to the traumatic event and alterations in reactivity and arousal associated with the trauma (Bryant, 2019). Kennedy has a traumatic experience during his childhood. He reports that other children always isolated him and always picked him up. Therefore, post-traumatic stress disorder should be considered a secondary differential for him.

Reflections: I believe that I developed an accurate diagnosis for Kennedy. I utilized evidence-based approaches in his assessment to develop the diagnosis. I also considered any factors that may be contributing to his current health status. Therefore, one thing that I would do should I encounter a similar patient in the future is to incorporate psychotherapy into the treatment process. Psychotherapy would help the patient to manage symptoms of generalized anxiety disorder and triggers of depressive symptoms (Strawn et al., 2018).

 

References

Bryant, R. A. (2019). Post-traumatic stress disorder: A state-of-the-art review of evidence and challenges. World Psychiatry, 18(3), 259–269. https://doi.org/10.1002/wps.20656

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of Internal Medicine, 170(7), ITC49–ITC64. https://doi.org/10.7326/AITC201904020

Diaconescu, A. O., Hauke, D. J., & Borgwardt, S. (2019). Models of persecutory delusions: A mechanistic insight into the early stages of psychosis. Molecular Psychiatry, 24(9), 1258–1267. https://doi.org/10.1038/s41380-019-0427-z

Kraus, C., Kadriu, B., Lanzenberger, R., Zarate Jr., C. A., & Kasper, S. (2019). Prognosis and improved outcomes in major depression: A review. Translational Psychiatry, 9(1), 1–17. https://doi.org/10.1038/s41398-019-0460-3

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: An evidence-based treatment review. Expert Opinion on Pharmacotherapy, 19(10), 1057–1070. https://doi.org/10.1080/14656566.2018.1491966

Subjective:

CC (chief complaint): Depression: According to the information provided by the patient’s parents, the patient appeared to be depressed, lacking energy, crying,expressing a desire to die and feeling worthless for destroying everyone’s lives.

HPI: The client is a sixteen-year-old female from Tacoma, Washington. She has been engaging in a lot of unprotected sex recently. Additionally, she has been stealing money from her mother’s purse to purchase clothing, makeup, and “other things.” She recently got discharged from a three-month teen residential mental health facility on a medication regimen consisting of Lithium 300 mg in the morning and 600 mg at bedtime, as well as Ariprazole 10 mg druing the morning hours.She has issues with medication compliance according to the statements that she made to her parents. Recent laboratory results were within normal ranges, and this included a negative urine toxicology test. However, the client tested positive for cannabis four months ago upon admission to the teen residential program. Sleep is reduced to three to four hours per day. Appetite “is fantastic.” The client is on birth control with an implant of Nexplanon.

Past Psychiatric History:

  • General Statement: The patient has a history of conduct disorder, depression, and aggression/violence directed at his mother as well as the two younger sisters during his childhood.
  • Caregivers (if applicable):
  • Hospitalizations: Three months in a residential mental health facility for adolescents last month
  • Medication trials: Sertraline – irritability, impulsivity, and aggression are exacerbated
  • Psychotherapy or Previous Psychiatric Diagnosis: Since the age of seven, I’ve struggled with conduct disorder and depression.

Substance Current Use and History: Cannabis – unknown quantity, frequency, and duration of use. Four months ago, prior to entering residential treatment, a urine toxicology test revealed a positive result for Cannabis.

Family Psychiatric/Substance Use History: Grandmother – history of bipolar disorder

Mother – history of anxiety

Maternal aunt – similar to mother

 

Psychosocial History: Client resides with her parents and two younger sisters in Tacoma, Washington. She is a sophomore in high school but is single at the moment. She identifies as bisexual. As a child, she engaged in domestic violence against her mother and two younger sisters. Client tested positive for Cannabis four months ago during his admission to a three-month teen residential psychiatric mental facility. Additionally, the client has a history of self-harm through cutting. Denies any legal ramifications.

Medical History:

 

  • Current Medications: Lithium 300 mg in the morning, Lithium 600 mg at bedtime, and Aripiprazole 10 mg in the morning.
  • Implantable Nexplanon.
  • Allergies: None were reported.
  • Reproductive Hx: Client engages in sexual activity with partners of both genders.

ROS:

  • GENERAL: alert, hyperactive, hyperverbal, and not in acute distress
  • HEENT: the provider should have conducted an examination.
  • SKIN: the provider should have conducted an examination.
  • CARDIOVASCULAR: the provider should have conducted an assessment
  • RESPIRATORY: the provider should have conducted an assessment
  • GASTROINTESTINAL: the provider should have conducted an assessment
  • GENITOURINARY: the provider should have conducted an assessment
  • NEUROLOGICAL: the provider should have conducted an assessment
  • MUSCULOSKELETAL: the provider should have conducted an assessment
  • HEMATOLOGIC: the provider should have conducted an assessment
  • LYMPHATICS: the provider should have conducted an assessment
  • ENDOCRINOLOGIC: the provider should have conducted an assessment

Objective:

Physical exam: if applicable

Temperature: 97.4

Pulse – 84

Respirations – 18

Blood Pressure – 134/88

Ht – 5’3

Wt – 118 lbs

BMI – 20.9

 

Diagnostic results: Laboratory values are within the normal range.

Urine toxicology results were negative.

Assessment:

Mental Status Examination:

Client is well-groomed and dressed appropriately for her age, the weather, and the occasion.

Fair eye contact

 

Hyper-verbal, pressed, and obnoxious speech.

 

Hyperactive behavior.

 

Psychomotor: agitated.

 

Euphoric mood.

 

Elated, consistent with mood

 

The Process of Thought: the flight of ideas

 

No delusions.

There are no suicidal, homicidal, or self-harming thoughts.

 

No response to external or internal stimuli.

 

Concentration/Attention: easily distracted.

 

Cognition: Aware, focused X 4.

 

Short- and long-term memory are both intact.

 

Poor insight

 

Poor judgment

 

Knowledge Base: Average.

 

Average intelligence.

Differential Diagnoses:

Bipolar disorder

Attention Deficit and Hyperactivity disorder

Major Depressive Disporder

 

Reflections:

Due to the patient’s mania, impulsivity, and excessive involvement in activities with a high risk of painful consequences, it appears necessary to admit her to an inpatient treatment facility. According to Malhi et al. (2018), more than 1% of the world’s population suffers from chronic Bipolar disorder, which typically begins in childhood. Bipolar disorder is one of the leading causes of disability worldwide, particularly among the younger population. Prompt and appropriate treatment can help avoid permanent damage caused by this disorder (Malhi et al., 2017). Bipolar disorder is a multifaceted disorder that necessitates compassionate care and painstaking ethical decision-making that takes the patient’s goals into account (Aref-Adib et al., 2019). When a provider is treating bipolar disorder, he or she must strike a balance between the principles of truthfulness, beneficence, and autonomy.

References

Aref-Adib, G., McCloud, T., Ross, J., O’Hanlon, P., Appleton, V., Rowe, S., … & Lobban, F. (2019). Factors affecting implementation of digital health interventions for people with psychosis or bipolar disorder, and their family and friends: a systematic review. The Lancet Psychiatry, 6(3), 257-266. https://doi.org/10.1016/S2215-0366(18)30302-X

Malhi, G. S., Morris, G., Hamilton, A., Outhred, T., & Mannie, Z. (2017). Is “early intervention” in bipolar disorder what it claims to be?. Bipolar disorders, 19(8), 627-636. https://doi.org/10.1111/bdi.12576