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PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Walden University PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Whether one passes or fails an academic assignment such as the Walden University PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

The introduction for the Walden University PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

After the introduction, move into the main part of the PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

 

CC (chief complaint):”medication refill”

HPI

DM is a 30-year-old AA female who has come to the clinic for medication refill. Patient reports that she has hx of paranoia and anxiety which led to her being admitted to the hospital about a year ago. Patient reports she was diagnosed with Bipolar II depressive type at the age of 19. After the discharge from hospital patient has been on the same medications as reports on her medication list. Patient states that her medications has been filled previously in a community clinicbut they refused to refill her medications as she had missed several visits and had not seen the Doctor for a long time due to the pandemic.

Patient reports she has mood swings frequently which have been well controlled  with medication and coping skills. Patient states that she has difficulty concentrating at times and finishing tasks and her mind is racing a lot of times. Patient reports she has a  full time job but she does not feel fulfilled as she has suffered a lot of losses in the past year and has not been in a relationship or been intimate with anyone since 2019.

Patient states that she is starting to get nervous and stressed because she does not want to be out of medications and end up in hospital again. Patient reports she does not have a lot of support system and mostly keeps to her self. Patient acknowledges that she build up things and does not express her feelings freely.

Patient does not report hallucinations, delusions, obsessions, or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain.

Patient currently denies suicidal ideation ( had hx of suicidal attempt when pt was 13 yo), denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.

Past Psychiatric History: Previous psychiatric diagnoses: Bipolar disorder II depressive type ( at age 19 years old). Patient was on the reported meds for the past years.

  • General Statement: 30 year old AA female here for medication refill.
  • Caregivers (if applicable): No caregivers
  • Hospitalizations: Manic episode- last admission was 2020 at PIW
  • Medication trials: haldol, seroquel, carbamazepin
  • Psychotherapy or Previous Psychiatric Diagnosis : Bipolar disorder II depressive type ( at age 19 years old). Pt was on the reproted meds for the past years.

Substance Current Use and History: Client denies use or dependence on nicotine/tobacco products.

Client does not report abuse of or dependence on ETOH, and other illicit drugs.

Family Psychiatric/Substance Use History: Bipolar from father side, no mental health from mother side. Pt is the only child. No reported knowledge of family history of substance use issues.

Psychosocial History: Occupational History: Patient is a 30 year old AA female, single, lives alone and has no social life. She is currently employed and denies military service.

Education history: started college, did not finish

Developmental History: no significant details reported.

Legal History: pt had hx of arrested but never convicted

Spiritual/Cultural Considerations: none reported.

Medical History:

  • Current Medications:
  • Benztropine 1 mg tablet every day by oral route at bedtime.
  • Oxcarbazepine 300 mg1 tablet twice a day by oral route with meals
  • Risperdal 2 mg tablet 1 tablet every day by oral route
  • Allergies: Peanut
  • Reproductive Hx: Menarche at 12years, regular peiods, no children

ROS:

  • GENERAL: Anxious female, looks older than stated age, seeking medication refill
  • HEENT: Eyes: no irritation or dry eyes.Ears: no difficulty hearing or ear pain. Mouth/Throat: no sore throat or dry mouth.
  • SKIN: Skin: no jaundice, rashes, laceration, or abnormal mole
  • CARDIOVASCULAR: Cardiovascular: no shortness of breath when walking or breath when lying down and no palpitations or chest pain.
  • RESPIRATORY: Respiratory: no cough, wheezing, shortness of breath, or coughing up blood.
  • GASTROINTESTINAL: no nausea, vomiting, constipation, diarrhea, dyspepsia, or abdominal pain and normal appetite
  • GENITOURINARY: Genitourinary: no incontinence or difficulty urinating
  • NEUROLOGICAL: : no weakness or loss of consciousness
  • MUSCULOSKELETAL: Musculoskeletal: no muscle aches or weakness and no back pain or swelling in the extremities
  • HEMATOLOGIC: : No bruises, bleeding, or anemia.
  • LYMPHATICS: has no history of splenectomy and has no swollen lymph nodes
  • ENDOCRINOLOGIC: : has no abnormal sweating or excessive thirst

Physical exam: if applicable

Diagnostic results:

GAD-7 Not scored
PHQ-2/PHQ-9 5 (for the PHQ-9)
MDHAQ Not scored

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Assessment

Mental Status Examination:

Appearance: well-groomed, clean, and normal weight. Behavior: calm, pleasant, eye contact, and guarded. Speech: fluent, clear, and soft. Perception: no hallucinations. Cognition: oriented to situation, time, place, and person and alert and memory intact. Intelligence: average . Memory: remote and recent. Mood: euthymic. Affect: anxious and flat and euphoric and congruent to thought content. Insight: intact. Judgment: intact. Thought Processes: intact. Thought Content: unremarkable. Motor Activity: intact.

Differential Diagnoses:

Bipolar II disorder

This patient has a history of previous hospitalization where a diagnosis of bipolar II(depressive type), was made. For a diagnosis of Bipolar II, the DSM-5 (2013) states it is characterized by at least one hypomanic episode and one or more major depressive episodes.

Patient has a history of attempted suicide at the age of 13, indicating a depressive episode and a family history of Bipolar disorder. According to O’Donovan, C. et al; (2020), of people presenting with an episode of major depression, a certain proportion may in reality be suffering from depression that is of bipolar type.

This could be for several reasons:  in many if not most cases bipolar disorder starts with symptoms of depression and first hypomania/mania may not appear until years later; depression is considered a part of the bipolar genetic spectrum and thus some forms of depression are conceivably variants of bipolar disorder, particularly in those with a strong family history

Major Depressive Disorder

Studies have shown there are distinct biomarkers that distinguish unipolar depression frommthe depressive state in Bipolar disorder. Menezes, I. et al; (2019) report that

Clinical studies have shown about 40%–50% of BPD patients are firstly erroneously diagnosed with MDD and the correct diagnosis use to be delayed about 8-10 years

BPD is characterized by recurrent episodes of depression and elevation of mood (mania and/or hypomania), being in a depressive state more frequent, longer and disabling than hypo/manic state in BPD .

Bipolar patients are more likely to have a family history of BPD, greater number of affective episodes, psychiatric hospitalization, suicide attempts, and earlier onset of the disease than unipolar depressed patients. This patient  was first diagnosed at 19, attempted suicide at 13, and has a family history of Bipolar disorder, making Bipolar II disorder my first choice as a differential diagnosis.

Attention Deficit Hyperactivity Disorder (ADHD)

Patient reports that her mind in constantly racing and she has difficulty concentrating and finishing tasks. Pinna, M. et al; (2019) state the symptomatology of BD and ADHD can overlap, with mood instability, distractibility, bursts of energy and restlessness, talkativeness, racing thoughts, impulsivity, impatience, impaired judgment, and irritability found in both disorders

While this is not my first choice, I believe more indepth interview may need to be carried out as patient may have ADHD as a comorbid condition with Bipolar disorder.

Reflections

In the course of doing this assignment, I came to realize how important it is for a mental health clinician especially, to thoroughly assess their clients,  and to rule out substance abuse dependence and medical conditions that may present as psychiatric disorders,  prior to making their diagnosis as even abnormalities of the immune system, including thyroid dysfunction, might be a potential factor contributing to the development of these mental disorders (Jucevičiūtė, N.et al; 2019).

Important legal documentation prior to treating patients was also evident in this case presentartion as patient had to sign  a release form in order to request medical record from previous Provider

All the appropriate tests, interviews and assessments were done prior to this patient being diagnosed with a bipolar 11 disorder-ruled out medical and drug causes of pt symptoms.  (medically stable with normal lab TSH,CBC,A1C. Pt denied the use of any street drug)

Although there is no record here indicating family and friends were interviewed, I would assume they were, as it is important to seek input of patient behavior from other close sources to make a this diagnosis of Bipolar 11.

According to Wheeler, K. (2014), while medication is considered the first line of treatment is Bipolar disorder, multiple studies have shown with increasing evidence that the course of the disease can be further modified by interventions that target the three factors associated with relapse in BD; stressful life events, medication non-adherence and disruptions in social rhythms. I would therefore suggest that this patient should in addition to medication which she clearly sought in this case presentation, be encouraged to participate in interpersonal psychotherapy.

 

References

Jucevičiūtė, N., Žilaitienė, B., Aniulienė, R., & Vanagienė, V. (2019). The link between thyroid autoimmunity, depression and bipolar disorder. Open Medicine, 14(1), 52-58.

Kaplan, H. I., Sadock, B. J., Boland, R. J., Verduin, M. L., Sadock, V. A., & Ruiz, P. (2021). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Wolters Kluwer.

Menezes, I. C., von Werne Baes, C., Lacchini, R., & Juruena, M. F. (2019). Genetic biomarkers for differential diagnosis of major depressive disorder and bipolar disorder: a systematic and critical review. Behavioural brain research, 357, 29-38.l

O’Donovan, C., & Alda, M. (2020). Depression preceding diagnosis of bipolar disorder. Frontiers in psychiatry, 11, 500.

 

Pinna, M., Visioli, C., Rago, C. M., Manchia, M., Tondo, L., & Baldessarini, R. J. (2019). Attention deficit-hyperactivity disorder in adult bipolar disorder patients. Journal of affective disorders, 243, 391-396.

 

Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse: a how-to guide for evidence-based practice.

 

American Psychiatric Association, & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA.

Sample Answer 2 for PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Subjective:

CC (chief complaint): “I feel sad and hopeless.”

HPI: R.T. is a 26-year-old White female who came to the psychiatric clinic accompanied by her male partner with complaints of feeling sad and hopeless. The feelings began about four weeks after delivering her firstborn son 14 weeks ago. She first thought that the sad feelings were the pregnancy blues that she had seen her sister experience, but her partner got worried when the sadness persisted and worsened over time. The client’s partner mentioned that R.T. has had intense sadness and despair in the past six weeks. She is tearful most of the day and does not find take pleasure in the activities she enjoyed before delivery. The partner also mentioned that the client has uncontrollable worries about her baby’s health and well-being. R.T. reported having sleeping difficulties and usually has frequent nighttime awakening that leaves her feeling tired during the day. She attributes the sleeping difficulties to being frequently woken up by the baby and having to wake up frequently to breastfeed him. Furthermore, she attributed the fatigue to having no one to help her with the baby since her partner is usually working during the day and comes late in the evening. The feelings of sadness have significantly interfered with her ability to function and the client’s partner is concerned that they would risk the health of the mother and infant. The client denies having suicidal ideations or ill feelings toward her baby.

Past Psychiatric History:

  • General Statement: The client has no significant psychiatric history.
  • Caregivers (if applicable): None
  • Hospitalizations: None
  • Medication trials: None
  • Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: The client reported taking whiskeys on weekends and using recreational marijuana before she got pregnant. She has not taken alcohol or used marijuana since she got pregnant.

Family Psychiatric/Substance Use History: She has a maternal aunt who had depression and committed suicide. The maternal grandmother had dementia.

Psychosocial History: R.T. lives with her partner in Rockville MD. She is a hotel supervisor and has a diploma in Hospitality management. She has one son 14 weeks old. The partner is a salesman in an insurance firm.  The client’s support system is her partner and elder sister.

Medical History:

 

  • Current Medications: OTC Tylenol for occasional headaches.
  • Allergies: Allergic to Sulfa drugs.
  • Reproductive Hx: Para 1+0. No history of gynecologic or obstetric disorders.

Objective:

Diagnostic results: No diagnostic tests were ordered for this patient

Assessment:

Mental Status Examination:

The client is well-groomed and appropriately dressed for the weather and function. She is alert and oriented to person, place, and time. She maintains adequate eye contact. The self-reported mood is sad and the affect is flat. Her speech is clear with normal rate and volume. She demonstrates a coherent, logical, and goal-directed thought process. No obvious delusions, hallucinations, obsessions, phobias, or suicidal ideations. She denies having negative feelings toward the child or thoughts about harming her child. Her long-term and short-term memory is intact. She demonstrates good judgment and insight is present.

Differential Diagnoses:

Postpartum Depression (PPD): PPD is a severe form of depression occurring in a woman in the first few weeks after childbirth. It develops in most cases in the first four months after delivery. It is characterized by sadness and frequent crying, loss of interest in the surrounding; loss of usual emotional response to the family; an intense feeling of unworthiness, guilt, and shame; generalized fatigue, irritability, and difficulty in concentrating; Anorexia and sleep disturbances (Yu et al., 2021). In addition, the woman has a tense irritable appearance, obsessive thoughts; persistent anxiety that makes her feel out of control; and lovingly cares for the infant but not feeling any love or pleasure (Anokye et al., 2018). PPD is the presumptive diagnosis based on the patient’s persistent feelings of sadness and hopelessness that started in the postpartum, sleeping difficulties, and increased fatigue. Besides, the feelings of sadness have significantly interfered with her ability to function, which is consistent with PPD.

Postpartum Blues: Postpartum Blues are characterized by a rapidly fluctuating mood, tearfulness, irritability, and anxiety. The symptoms peak on the fourth or fifth-day post-delivery and last several days. The symptoms are generally time-limited and spontaneously abate within the first two weeks postpartum (Luciano et al., 2021). Unlike PPD, the symptoms of Postpartum blues do not impede a mother’s ability to function and care for the child. The patient’s depressed mood after delivery makes Postpartum Blues a likely diagnosis. However, the patient’s symptoms have persisted making this an unlikely diagnosis.

Postpartum Psychosis: This is a mental disorder that occurs in childbirth characterized by deep depression, delusions of the infant’s death, and homicidal feelings towards the child. The affected woman presents with changes in mood states, irrational behavior and agitation, fear, and perplexity as she quickly loses touch with reality (Perry et al., 2021). The signs and symptoms of Postpartum psychosis include restlessness, agitation, confusion, suspicion, insomnia, hyperactive episodes, disorder of thought process, talking rapidly and incessantly, being overactive and elated, profound depressive mood, and loss of memory and concentration. In addition, the woman has mood swings sometimes with inappropriate emotion, neglects basic needs, experiences difficulties with lactation, and has reduced sexual response (Perry et al., 2021). Postpartum psychosis is a differential based on the positive symptoms of depressed mood and insomnia. However, the patient’s symptoms do not meet the criteria for Postpartum psychosis, ruling it out as a primary diagnosis.

Reflections:

In a similar patient situation, I would have assessed the patient for risk factors of PPD like marital dysfunction or difficult relationship with significant others, anger about the pregnancy, feeling of isolation, or lack of social support (Yu et al., 2021). Low socioeconomic status is a social determinant of health (SDOH) linked with PPD. Adynski et al. (2019) explain that women with low-income levels tend to have financial worries during and after pregnancy, which increases the risk of PPD. Besides, lack of insurance hinders access to postpartum care where they can be diagnosed and treated early for PPD. Health promotion will focus on recommending the woman to acknowledge her feelings and insist that others acknowledge them too. The partner will be recommended to continue communication with the client and encourage continued contact with other adults (Anokye et al., 2018). Health education will focus on teaching the patient the importance of good nutrition and adequate rest in the postpartum period.

Case Formulation and Treatment Plan:

The client has insomnia, adjustment difficulties, and difficulty coping with daily stressors associated with motherhood.

Psychotherapy: The patient was initiated on individual psychotherapy comprising cognitive-behavioral and interpersonal therapy. She will also be introduced to a support group for new nursing mothers (Anokye et al., 2018).

Follow-up: The patient will be scheduled for a follow-up after four weeks to assess the progress of PPD symptoms with psychotherapy. Pharmacologic therapy will be recommended if her condition does not respond to psychotherapy.

 References

Adynski, H., Zimmer, C., Thorp, J., Jr, & Santos, H. P., Jr (2019). Predictors of psychological distress in low-income mothers over the first postpartum year. Research in nursing & health, 42(3), 205–216. https://doi.org/10.1002/nur.21943

Anokye, R., Acheampong, E., Budu-Ainooson, A., Obeng, E. I., & Akwasi, A. G. (2018). Prevalence of postpartum depression and interventions utilized for its management. Annals of general psychiatry, 17, 18. https://doi.org/10.1186/s12991-018-0188-0

Luciano, M., Sampogna, G., Del Vecchio, V., Giallonardo, V., Perris, F., Carfagno, M., Raia, M. L., Di Vincenzo, M., La Verde, M., Torella, M., & Fiorillo, A. (2021). The Transition From Maternity Blues to Full-Blown Perinatal Depression: Results From a Longitudinal Study. Frontiers in psychiatry, 12, 703180. https://doi.org/10.3389/fpsyt.2021.703180

Perry, A., Gordon-Smith, K., Jones, L., & Jones, I. (2021). Phenomenology, Epidemiology, and Aetiology of Postpartum Psychosis: A Review. Brain sciences, 11(1), 47. https://doi.org/10.3390/brainsci11010047

Yu, Y., Liang, H. F., Chen, J., Li, Z. B., Han, Y. S., Chen, J. X., & Li, J. C. (2021). Postpartum Depression: Current Status and Possible Identification Using Biomarkers. Frontiers in psychiatry, 12, 620371. https://doi.org/10.3389/fpsyt.2021.620371

Sample Answer 3 for PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

CC (chief complaint): “I do not see any does not see any benefits with my medications.”

HPI:

RR is a 21-year-old Asian male who presents for a follow-up visit for ADHD and medication management. He reports that he does not see any benefits with his medications, and the current Adderall medication makes him more tense. He states that he does not want to go the stimulant way. RR reports having increased anxiety and depressive symptoms. The client reports that he is still experiencing insomnia and he is too tired to work or engage in physical exercises. Besides, he states that he does not currently have a therapist but will work on having one when he starts school. However, he mentioned that he watches a lot of sports and spends time with his family.

Past Psychiatric History:

  • General Statement: The client first presented for psychiatric evaluation due to ADHD.
  • Caregivers (if applicable): None
  • Hospitalizations: None
  • Medication trials: None
  • Psychotherapy or Previous Psychiatric Diagnosis: Rejection Sensitive Dysphoria

Substance Current Use and History: He denies drug substance use, smoking, or taking alcohol.

Family Psychiatric/Substance Use History: No history of psychiatric or SUDs in the family.  

Psychosocial History: RR lives with his parents and his younger sister. He is currently waiting to join university to study Theatre Arts. His hobbies include watching sports and acting, and he was a member of the Drama club in high school. He reports sleeping 3-4 hours daily with poor quality sleep due to insomnia.

Medical History:

 

  • Current Medications: Adderall 5mg, guanfacine 1 mg, and Wellbutrin SR 100 mg daily.
  • Allergies: None
  • Reproductive Hx: No history of STIs.

ROS:

  • GENERAL: Positive for increased fatigue. Denies fever, weight changes, or malaise.
  • HEENT: Denies head injury, eye pain, excessive lacrimation, diplopia or blurred vision, ear pain/discharge, sneezing, nasal discharge, or pain when swallowing.
  • SKIN: Negative for itching, rashes, or lesions.
  • CARDIOVASCULAR: Denies dyspnea, edema, chest pain, or racing heart.
  • RESPIRATORY: Denies cough, chest pain, wheezing, or difficulties in breathing.
  • GASTROINTESTINAL: Denies abdominal distress, vomiting, or bowel changes.
  • GENITOURINARY: Denies pelvic pain, dysuria, or blood in the urine.
  • NEUROLOGICAL: Denies muscle weakness, paralysis, dizziness, or numbness.
  • MUSCULOSKELETAL: Negative for limitations in movement.
  • HEMATOLOGIC: Negative for bleeding or hx of anemia.
  • LYMPHATICS: Denies lymph node swelling.
  • ENDOCRINOLOGIC: No excessive perspiration, heat/cold intolerance, or polyuria.

Diagnostic results: No results available.

Assessment

Mental Status Examination:

Male client in his early 20’s. He is calm, alert, neat, and appropriately dressed. He maintains adequate eye contact and exhibits a positive attitude toward the clinician. The client has clear speech with normal rate and volume, and his thought process is goal-directed and logical. He denies auditory/visual hallucinations, homicidal ideations, or suicide ideations. No delusions, obsessions, or phobias were noted. His memory is intact, and he demonstrates good judgment.

Differential Diagnoses:

Attention Deficit Hyperactive Disorder (ADHD): ADHD manifests with impulsivity, hyperactivity, and inattention. Patients with the inattentive type are easily distracted, forgetful, disorganized, and do not follow instructions (Cabral et al., 2020). The patient had been previously diagnosed with ADHD and is on a follow-up visit. ADHD continues to be the primary diagnosis.

Generalized Anxiety Disorder (GAD): GAD presents with persistent and excessive anxiety or worries about everything. Other symptoms include restlessness, easy fatigue, concentration difficulties, muscle tension, irritability, and sleep disturbance (DeMartini et al., 2019). GAD is a likely diagnosis based on the client’s positive symptoms of fatigue, insomnia, and increased anxiety levels.

Major Depressive Disorder (MDD): MDD is a severe mood disorder that presents with persistent feelings of sadness and hopelessness and loss of interest in activities one previously enjoyed. Other clinical features include significant weight changes, sleep disturbances, fatigue, feelings of worthlessness, reduced capacity to think/concentrate or indecisiveness, and recurrent thoughts of death or suicidal ideations (Christensen et al., 2020). MDD is a differential based on the patient’s symptoms of fatigue, insomnia, and worsening depressive symptoms.

Reflections:

I agree with the preceptor’s diagnostic impression of ADHD since the patient did not exhibit other significant symptoms to warrant the diagnosis of MDD or GAD as the primary diagnosis. Patients with ADHD often have co-existing depression and anxiety symptoms similar to this patient. The preceptor stopped the patient’s Adderall, Guanfacine, and Wellbutrin treatment and discharged the patient for inability to manage medication. The PMHNP should implement treatment interventions associated with the best outcomes for ADHD patients. In this regard, I would have referred the patient for psychotherapy to help manage the ADHD, anxiety, and depression symptoms (Tourjman et al., 2022). Health promotion for this patient should focus on promoting healthier lifestyle practices with regard to diet and exercise. The patient should be recommended to exercise at least 30 minutes daily since it alleviates the severity of ADHD symptoms and improves cognitive functioning (Drechsler et al., 2020). Besides, he should be advised to eat foods that lower inflammation in the body as it helps the brain function better. This includes consuming more fruits, vegetables, and omega-3 fatty acid-rich foods like salmon or tuna and reducing the intake of white flour, processed foods, and sugar.

References

Cabral, M., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational pediatrics, 9(Suppl 1), S104–S113. https://doi.org/10.21037/tp.2019.09.08

Christensen, M. C., Wong, C., & Baune, B. T. (2020). Symptoms of Major Depressive Disorder and Their Impact on Psychosocial Functioning in the Different Phases of the Disease: Do the Perspectives of Patients and Healthcare Providers Differ?. Frontiers in psychiatry, 11, 280. https://doi.org/10.3389/fpsyt.2020.00280

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

Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current Concepts and Treatments in Children and Adolescents. Neuropediatrics, 51(5), 315–335. https://doi.org/10.1055/s-0040-1701658

Tourjman, V., Louis-Nascan, G., Ahmed, G., DuBow, A., Côté, H., Daly, N., Daoud, G., Espinet, S., Flood, J., Gagnier-Marandola, E., Gignac, M., Graziosi, G., Mansuri, Z., & Sadek, J. (2022). Psychosocial Interventions for Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis by the CADDRA Guidelines Work GROUP. Brain sciences, 12(8), 1023. https://doi.org/10.3390/brainsci12081023

Sample Answer 4 for PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Initials: D.S

Sex: Female

Age: 34 years

CC (chief complaint): “I often experience chest pain that feels like a heart attack. My panics get worse by day, and I fear having them in public.”

HPI:  D.S is a 34-year-old White female who presented with a chief complaint of frequent chest pain that she perceives as a heart attack.  She also reported that she experiences abrupt panics that are worsening over time. The patient reported that she lives in worry of experiencing a panic attack, especially in public places. D.S explained that she experiences an abrupt, unexpected, and spontaneous onset of fear, which lasts about 10 minutes. This has occurred for the past 6 weeks, and she thinks that it could be panic attacks. In addition, she reported that when she is experiencing a panic attack, her heart pounds faster and feels like it is racing. She also shakes a lot, has unusual sweating with a hot sensation, and feels like she is choking. The patient also reported that she experiences shortness of breath when having chest pain and experiences an uncontrolled fear of death.

Past Psychiatric History:

  • General Statement: No significant psychiatric history.
  • Caregivers (if applicable): None
  • Hospitalizations: No history of psychiatric admission.
  • Medication trials: None
  • Psychotherapy or Previous Psychiatric Diagnosis: No history of psychotherapy or psychiatric diagnosis.

Substance Current Use and History: Reports taking beer 2-3 cans about 3 days a week and recreational marijuana. She denies a history of tobacco smoking or use of other drug substances.

Family Psychiatric/Substance Use History: The elder brother has a history of Cocaine abuse. Maternal grandmother had Alzheimer’s.

Psychosocial History: D.S was born in Houston, TX, and raised by her parents alongside her two brothers.  She currently lives in Dallas with her husband and two children aged 8 and 4 years. She has studied up to Bachelor’s level and works as an accountant in an insurance company. The patient reported attending her well-exams annually. Her hobbies include hiking, skiing, and baking. She reported having an active lifestyle, and she engages in physical exercises for at least one hour per day. D.S denies having any legal history.

Medical History:  No history of chronic illness or surgery. Last Flu shot- 7 months ago.

  • Current Medications: Vitamin C supplements.
  • Allergies: Allergic to Sulfur.
  • Reproductive Hx: No history of reproductive disorders. Para 2+0. Contraception method- IUD for 3 years.

ROS:

  • GENERAL: Reports having heat sensations. Denies fever, weight changes, or general weakness.
  • HEENT: Denies headache, vision changes, ear pain/discharge, nasal discharge, sneezing, or throat pain.
  • SKIN: Denies rashes or lesions.
  • CARDIOVASCULAR: Positive for pounding heart, palpitations, chest pain, SOB, and choking sensation. Negative for edema.
  • RESPIRATORY: Positive for SOB and chest pain. Negative for cough, sputum, or wheezing.
  • GASTROINTESTINAL: Denies nausea, vomiting, loss of appetite, abdominal pain, or bowel changes.
  • GENITOURINARY: Denies pelvic pain, abnormal PV discharge, dysuria, or urinary urgency/frequency.
  • NEUROLOGICAL: Denies headache, dizziness, paresthesias, or muscle weakness.
  • MUSCULOSKELETAL: Negative for limitations in movement.
  • HEMATOLOGIC: Denies bruising or bleeding.
  • LYMPHATICS: Denies lymph node enlargement.
  • ENDOCRINOLOGIC: Positive for excessive sweating. Denies excessive urination, cold/heat intolerance, or acute thirst.

Physical exam:

Vital signs: BP- 118/74; HR- 94; RR- 18; Temp- 98.06

Respiratory: Uniform chest rise and fall with smooth respirations. Lungs clear on auscultation and percussion.

Cardiovascular: No neck vein distension or edema of lower limbs. Normal heart rate and rhythm. S1 and S2 present. No gallop sounds, murmurs, or friction rub.

Diagnostic results: No diagnostic tests were requested at this point.

Assessment

Mental Status Examination:

The patient was well-groomed and appropriately dressed for the function and weather. Eye contact was limited at the beginning but improved during the interview. The self-reported mood was ‘anxious’. Affect was broad. The speech was clear with normal volume and rate. Coherent thought process. No hallucinations, delusions, phobias, or obsessions were observed. The patient denied having suicidal ideations. Memory was grossly intact, and the patient demonstrated good judgment. Insight was present.

Differential Diagnoses:

Panic Disorder

The DSM-5 criteria for Panic disorder include experiencing recurrent panic attacks, with one or more attacks followed by at least one month of fear of another panic attack or significant maladaptive behavior related to the attacks (APA, 2013). A panic attack is a sudden period of intense fear or discomfort (Ströhle et al., 2018). It is accompanied by four or more of the following systemic symptoms: Palpitations, pounding heart, or accelerated heart rate; Trembling or shaking; Sweating; Shortness of breath; Feelings of choking; Chest pain or discomfort; Nausea or abdominal distress; Dizziness or lightheadedness; Chills or heat sensations; Paresthesias; Feeling of unreality or being detached from oneself; Fear of losing control or going crazy; and fear of dying (APA, 2013).

Panic Disorder was a differential diagnosis based on the patient’s report of having abrupt unexpected and spontaneous onset of fear. Pertinent positive symptoms include chest pain, shortness of breath, palpitations, pounding heart, sweating, choking sensation, heat sensations, and an uncontrolled fear of death. Besides, the patient reported having fear of experiencing a panic attack in a public place.

Generalized anxiety disorder (GAD)

GAD manifests with excessive anxiety and worries about various events and activities. The worry is usually difficult to control (Ströhle et al., 2018). Anxiety and worry occur with at least three of the following symptoms occurring more days than not for at least six months: Restlessness or feeling on edge; Easy fatigue; Concentration difficulties or mind going blank; Irritability; Muscle-tension; and Sleep disturbance (APA, 2013). GAD was a differential diagnosis based on the patient’s history of experiencing fear and being worried about experiencing a panic in public. However, the patient’s symptoms did not fit the criteria for GAD and ruled it out as a primary diagnosis.

Unstable Angina

Symptoms of unstable angina are similar to those of myocardial infarction include chest pain or pressure and pain or pressure radiating from the chest to the neck, jaw, back, abdomen, or upper limbs. Other symptoms include sweating, dyspnea, nausea, vomiting, dizziness or abrupt weakness, and fatigue (Thomsett & Cullen, 2018). The symptoms may occur at rest; become more frequent, severe, or prolonged than the usual pattern of angina; or change from the usual pattern of angina (Thomsett & Cullen, 2018). Unstable Angina was a differential diagnosis based on pertinent positive symptoms of chest pain, shortness of breath, and sweating. However, the patient did not have any positive symptoms on cardiovascular exam or history of cardiac disease, which ruled out Unstable Angina as a likely primary diagnosis.

Reflections:

The case enlightened me on the various types of anxiety disorders, including their DSM V diagnostic criteria. I agree with the preceptor’s diagnosis of Panic Disorder because the patient did not have cardiovascular physical findings or a history of cardiovascular conditions that would point to cardiac disease (Kim, 2019). Besides, the symptoms were in line with the DSM V criteria for Panic Disorder Legal and ethical considerations for this patient should include autonomy, beneficence, nonmaleficence, and confidentiality. The PMHNP, in this case, should uphold the patient’s autonomy by involving her in planning for care and respecting her treatment decisions (Kim, 2019). Beneficence and nonmaleficence can be upheld by analyzing treatment interventions to ensure they will promote the best possible outcomes and not cause harm to the patient. Furthermore, the PMHNP should uphold the confidentiality of the patient’s information and seek consent before sharing the information with another provider. Health promotion should focus on educating the patient about the panic disorder to understand that the symptoms are not life-threatening (Kim, 2019). She should also be taught to recognize the triggers of panic attacks and avoid them.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Kim, Y. K. (2019). Panic Disorder: Current Research and Management Approaches. Psychiatry Investigation, 16(1), 1–3. https://doi.org/10.30773/pi.2019.01.08

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The Diagnosis and Treatment of Anxiety Disorders. Deutsches Arzteblatt international, 155(37), 611–620. https://doi.org/10.3238/arztebl.2018.0611

Thomsett, R., & Cullen, L. (2018). The assessment and management of chest pain in primary care:’A focus on acute coronary syndrome’. Australian Journal of general practice, 47(5), 246. https://doi.org/10.31128/AFP-08-17-4304