Comprehensive Psychiatric Evaluation Assessment

Comprehensive Psychiatric Evaluation Assessment

Comprehensive Psychiatric Evaluation Assessment

Name: Mrs. I. F

Age: 47-year-old

Sex: Female

Source: Husband

CC (chief complaint): “My wife flipped a switch after the recent school shooting and she is constantly worried about our kids. She is watching the news 24/7, barely sleeping, and even when she does, it is only a few hours,”

HPI: I.F is a 47-years-old woman who was referred by her husband for psychiatric evaluation for anxiety. The husband reports that after a recent school shooting the patient “flipped a switch”. The patient barely sleeps and she watches the news 24/7. The patient admits that she has stronger feelings about losing people.  She reports losing her parents when she was 19 years old. A drunk driver sideswiped her parents, pinning them to the freeway median. Her worries have increased of late due to a recent school shooting. She states that she has withdrawn her children from school since the public schools can’t afford protection for the children. She homeschools them nowadays and believes that her friends will withdraw their kids from school. She reports that her worries are not based on frantic phobia because she is educated about these matters. She states that her husband does not understand what it is like to lose a family that is why he sent her to a shrink. She concludes by stating that “I can prevent another Adam Lanza from pointing a gun at my babies. I won’t send them back to school. I won’t turn off the television, and I won’t stop informing myself. I will do what I can as a mother to protect my children.”

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Past Psychiatric History: The patient has no history of mental health or substance use

treatment

Psychotherapy or Previous Psychiatric Diagnosis:  None.

Substance Abuse History: The patient denies any history of use of caffeine, nicotine, illicit substance, or alcohol.

Family Psychiatric/Substance Use History: No family history.

Social History: The was born and raised in Northern Ireland, her parents brought her and her one sister to the U.S. when she was 15 to go to U.S. university where she met her husband. They live in Charleston, SC. She has a master’s degree in education and used to work from home but she quit her job five years ago after her last child, Colin. Her current hobby is watching CNN as she clears her laundry and prepares lessons for her homeschooling kids. She has no legal history but reports witnessing her parents die in a road accident when she was 19 years. A recent school shooting has heightened her worries and she states she is ready to do anything to protect her children.

Medical History: Patient has a Hx of hysterectomy

Current Medications: None.

Allergies: NKDA.

Reproductive Hx: Deferred.

ROS:

GENERAL: Denies fever weight loss/weight gain, lethargy, or weakness.

HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: Denies rashes, moles, acne, itching, sores, dryness, changes in color, and changes in hair or nails. Denies easy bruising.

CARDIOVASCULAR: Denies chest pain, palpitations, SOB, fatigue with exertion, edema, or orthopnea.

RESPIRATORY: Denies cough or shortness of breath.

GASTROINTESTINAL: Denies diarrhea or constipation, and abdominal pain. Reports loss of appetite. Denies indigestion, reflux, or dysphagia.

GENITOURINARY: Denies dysuria, polyuria, hematuria, or incontinence.

NEUROLOGICAL: Denies dizziness, weakness, numbness, or tingling. Reports increased anxiety and worry about the safety of her children. 

MUSCULOSKELETAL: Denies hypotonic, hypertonic pain, or weakness.

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Denies enlarged nodes or a history of splenectomy.

ENDOCRINOLOGIC: Denies increased thirst, cold, or heat intolerance.

Physical Exam

GENERAL:

Vital Signs: T- 98.0 P- 82 R 18 136/62 Ht 5’0 Wt 123lbs

HEENT: Normocephalic and atraumatic. Sclera white, conjunctiva pink; PERRLA, Nasal mucosa mild-to-moderately erythematous and edematous. Oral mucosa pink with no lesions, tongue midline and pharynx without exudates.

NECK: Neck reveals no carotid bruits, no JVD, and no lymphadenopathy. There is no

evidence of thyromegaly.

CHEST/LUNG: Chest expansion is symmetrical. Lungs are clear to auscultation and

percussion bilaterally.

HEART: Heart has a regular rate and rhythm. Normal S1 and S2.

Abdomen: Abdomen is soft, benign, non – tender. Bowel sounds are normoactive. No

CVA tenderness

Diagnostic results:

The patient developed fears and worries after a recent school shoot-out three weeks ago. It is essential to use DSM-5 criteria for acute stress disorder to diagnose the patient.  DSM-5 describes ASD as the development of specific fear behaviors that last from 3 days to 1 month after a traumatic event (Bryant, 2018). Further, the DSM-5 criteria offer an essential diagnostic tool to execute differential diagnoses and get a conclusive diagnosis. According to the criteria, the patient should have a stressor like direct exposure to death, serious injury or sexual violence, or witnessed a trauma. They should also project with intrusion symptoms like unwanted upsetting memories, nightmares, flashbacks, emotional distress, or physical reactivity. The third criterion is avoidance where the patient either avoids trauma-related thoughts or feelings or trauma-related external reminders. Patients should showcase negative alterations in cognition and mood. They can either not recall key features of the trauma, have overly negative thoughts, exaggerate blame, have a negative affect, feel isolated, diminished interest in activities, or have difficulty experiencing positive affect. Alterations in arousal and reactivity are also needed like difficulty sleeping, difficulty concentrating, heightened startle reaction, hypervigilance, irritability, and risky or destructive behavior (Bryant, 2018).  The symptoms should last between 3 days to 1 month, create distress or functional impairment, and are not linked to medication, substance abuse, or other illness.

Assessment

Mental Status Examination:

The patient is a 47-year-old Irish female who looks her stated age. She is cooperative and appropriately dressed for the age and season. Her speech is clear and coherent with a normal volume and tone. She projects a negative affect with delusional thinking without looseness of association or flight of ideas. She projects increased vigilance with a persistent negative emotional state. She denies auditory or visual hallucinations as well as suicidal and homicidal ideation.  She is alert and oriented with her recent and remote memory intact. Her concentration and insight are good.

Differential Diagnosis

Acute Stress Disorder:

The patient presentation aligns with the DSM-5 criteria for ASD. She reports experiencing a shocking event where she lost her parents at the age of 19. A recent school shoot-out three weeks ago triggered her traumatic experience causing emotional distress and a need to protect her children. She has withdrawn her children from public school to avoid exposure to traumatic incidence. She states that she sees the children’s faces from the shoot-out. She has overly negative thoughts about losing her children and assert that she is not ready to lose anyone she loves as she lost her parents. She blames herself because she could not have prevented her parents from the accident and therefore has to do everything possible to protect her children. She also has a negative affect. She barely sleeps and is hypervigilant by watching TV all the time to get informed and to protect her children. Her symptoms were triggered three weeks ago after the school shoot-out. The symptoms are not linked to medication, substance abuse, or other illnesses.

Post-Traumatic Stress Disorder

Post-traumatic stress disorder and ASD share similar symptoms. They also follow similar DSM-5 criteria since a patient must have a stressor, intrusion symptoms, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reaction (Çelik, 2018). The diagnosis is ruled out because PTSD symptoms begin within three months of the traumatic incidents or even years afterward.

Generalized Anxiety Disorder

According to the DSM-5, GAD is diagnosed when a patient has excessive anxiety and worry that occurs for more days and lasts for at least 6 months (Park & Kim, 2020). The patient cannot control the worry and it results in restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tensions, or sleep disturbances. The symptoms should cause clinically significant distress or impair functional areas. It should not be linked to substance abuse or other illness. The patient projects uncontrollable worry that has resulted in sleep disturbances, restlessness, and muscle tension. It has caused clinically significant distress and cannot be linked to drug abuse or medication. However, the diagnosis is ruled out because the symptoms have not lasted for six months and can be linked to reminders of traumatic events in PTSD (Park & Kim, 2020).

Reflection

The current case showcases the impact of a traumatic event on an individual. The patient is emotionally affected especially because the shoot-out event triggers another traumatic event that occurred when she was 19 years old. The preceptor’s conclusion that the patient has ASD is agreeable because ASD refers to intense, unpleasant, and dysfunctional reaction that occurs shortly after a traumatic event and last less than a month. A PTSD diagnosis cannot be confirmed because the symptoms have not persisted longer than a month. The case study instills a need to understand mental disorders symptoms and distinguishing factors to avoid the wrong diagnosis.

The moral and ethical sanctity of confidentiality is a basic need when handling mental health disorders. Nevertheless, psychiatrists are expected to anticipate the needs of their patients and come up with strategies to minimize harm to their patients. They should also not discriminate against a mental patient by subjecting them to abusive, violent, or degrading treatment. Conditions in places where a person lives, learns, works, and plays impact health risks and outcomes. For instance, the proximity of the current patient to a traumatic event resulted in emotional distress that manifested as a mental disorder. It is essential to engage and empower individuals and communities to adopt healthy behaviors and make changes that limit the development of chronic disease and other morbidities. In approaching the patient differently, I would avoid prompting discussion of issues that cannot be resolved and avoid pressuring her on subjects she does not wish to discuss.

References

Alexander Street. (2017). Training Title 85.https://video.alexanderstreet.com/embed/training-title-85

Bryant, R. A. (2018). The current evidence for acute stress disorder. Current psychiatry reports, 20(12), 1-8. https://doi.org/10.1007/s11920-018-0976-x

Çelik, F. (2018). Clinical manifestations of post-traumatic stress disorder. Klinik Psikofarmakoloji Bulteni, 28, 334-334.

Park, S. C., & Kim, Y. K. (2020). Anxiety Disorders in the DSM-5: changes, controversies, and future directions. Anxiety Disorders, 187-196. https://doi.org/10.1007/978-981-32-9705-0_12

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Assignment: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD
“Fear,” according to the DSM-5-TR, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2022). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease.
For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5-TR criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5-TR criteria.
To Prepare:
• Utilize the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation.
• Utilize video case study below for this Assignment, view your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
• 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.
• Utilize SafeAssign Drafts for originality report. Similarity report must be under 35%.
• Utilize at least 3 peer reviewed, scholarly sources.

*Please note that the video cases may not have all the necessary information needed for your evaluation. Supplementary case histories are provided. Rather than write “not provided” in your evaluations, be sure to use the fact sheets to fill in gaps. For any information still missing, explain what information is needed and why it is important.
The Physical Exam portion will rarely to never be “non-applicable.” Please READ YOUR RUBRIC CAREFULLY.
**Complete and submit your Comprehensive Psychiatric Evaluation, 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.
• Reflection notes: What would you do differently with this client if you could conduct the session over? 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.).

Link fot Video Case to use for assignment
https://video.alexanderstreet.com/embed/training-title-85

Case History Report for Video Case

Training Title 85

Name: Mrs. Isla Flanagan
Gender: female
Age: 47 years old
T- 98.0 P- 82 R 18 136/62 Ht 5’0 Wt 123lbs
Background: Born and raised in Northern Ireland, parents brought her and her one sister to U.S.
when she was 15 to go to U.S. university where she met her husband. They live in Charleston,
SC. She obtained her master’s degree in education; no history of mental health or substance use
treatment, no family history. Her husband reported a recent school shooting nearby 3 weeks ago
“flipped a switch” in her. She is watching the news 24/7, barely sleeping, and even when she
does, it is only a few hours, Appetite is decreased. Hx of hysterectomy, NKDA, no legal hx.
Symptom Media. (Producer). (2017). Training title 85 [Video]