Comprehensive Psychiatric Evaluation Essay

Comprehensive Psychiatric Evaluation Essay

Comprehensive Psychiatric Evaluation Essay

CC (chief complaint): “I can’t sleep at night, anxiety and pain in my chest. I keep hearing things”.

HPI:

The client is a 39-year-old white  female who is here for an annual psychiatric evaluation. She has had past mental health such as Major Depressive Disorder, Generalized anxiety disorder (GAD), and schizoaffective disorder. She is currently taking Vraylar, Seroquel, Trazodone, Prazosin, Diazepam, and Propranolol. She currently rates her depression as an 8/10 with symptoms of feeling down, low energy, loss of motivation (LOM), loss of pleasure (LOP), and difficulty concentrating for greater than 4years. She stated that she can’t concentrate in group settings, is easily distracted. She reports feeling anxious all the time and always worrying. She has racing thoughts, + mood fluctuations, + auditory hallucinations (AH), denies visual hallucinations (VH), and + paranoia (suspicious). No evidence of mania or delusions. She denies any inpatient hospitalization. When her mental health was at its worse, she reported that she couldn’t get out of bed, didn’t wash, and had feelings of helplessness and hopelessness, and worthlessness and that she is an embarrassment to her family. She denies past suicidal attempts. No current or recent SI or HI. No history of self-harm and she has a trauma history of physical, sexual, and emotional abuse. She is unable to go into detail about her trauma. She reports having night terrors and flashbacks. She has a therapist that she sees weekly.  No current safety issues. Previous medications she tried included Buspar, Lexapro, Prozac, Paroxetine, Celexa, Zoloft, Effexor, Risperdal, Neurontin, and Abilify she reports were all ineffective.

ORDER A PLAGIARISM-FREE PAPER HERE ON; Comprehensive Psychiatric Evaluation Essay

Columbia suicide scale:  1-no 2-no

Substance Current Use: Denies.

Medical History: HTN, Chronic back, and neck pain (Followed by Cardiologist)

• Current Medications: Norvasc 5mg, Hyzaar 100mg-12.5mg, and Metoprolol 25mg
• Allergies:No known drug allergies (NKDA) and no known food allergies (NKFA).
• Reproductive Hx:2 SVDs (2011 and 2015)

Family Psychiatric/Substance Use History:

The client denies a past psychiatric history on her maternal and paternal sides of the family. One younger brother with no mental health issues.

Psychosocial History:

            The client is a 39-year-old female born in Russia and relocated to New Hampshire at the age of 21. She came to Camden, DE, in 2016. She grew up in a home with both parents, she has one younger brother. She is married and takes care of her husband who is a disabled veteran and 3 children. Her parents recently moved into the home to help take care of her 3 children. Her parents are very supportive. Her relationship with her husband and children is good. Her highest level of education graduated with a bachelor’s degree. She currently does not have any hobbies. She is currently mentally disabled and is financially stable with her disability. She has no past legal history or current issues. Positive history of trauma previously noted and currently no safety issues.

ROS:

• GENERAL: Negative for fever, chills, weight gain/loss, and positive for low energy.
• HEENT: Negative for blurred vision, eye pain, ear pain/discharge, hearing loss, nasal discharge, sneezing, or sore throat.
• SKIN: Negative for rash, discoloration, or bruises.
• CARDIOVASCULAR: Positive for chest pain, and palpitations no edema.
• RESPIRATORY: Negative for sob, cough, sputum, or chest pain that is respiratory-related.
• GASTROINTESTINAL: Negative for nausea, vomiting, epigastric pain, or bowel changes.
• GENITOURINARY: Negative for dysuria, or urinary frequency/urgency.
• NEUROLOGICAL: Negative for headache, dizziness, fatigue, muscle weakness, tingling sensations, and +pain in the neck.
• MUSCULOSKELETAL: Negative for muscle pain, joint stiffness, or joint pain.
• HEMATOLOGIC: Negative for bleeding and bruising. 
• LYMPHATICS: Negative for enlarged lymph nodes.
• ENDOCRINOLOGIC:  Negative for sweating, cold/heat intolerance, excessive thirst, hunger, or urine production. 

Objective

Vital Signs: Temp- 98.6; P- 92; R-18; BP-144/88; Ht-5’1; Wt-138lbs

Diagnostic results: There are currently no test results available.

Mental Status Examination:

Female client in her late 30’s. She is AAOx3 but appears anxious. She is well-groomed and cooperative. She is dressed appropriately. She maintains good eye contact during the visit, has normal motor activity, and uses facial expressions appropriately. The self-reported mood is anxious, and the affect is appropriate. Her speech is clear with normal volume and tone, she has a logical and goal-directed thought process. There was no evidence of delusions and is having + auditory hallucinations, denies visual hallucinations, obsessions, or suicidal ideation/thoughts. Her short- and long-term memories are intact, his concentration is fair, and she possesses good judgment.

Differential Diagnoses

Schizoaffective disorder: Schizoaffective disorder is characterized by features of both schizophrenia and a mood disorder (depression or mania). A person is diagnosed with schizoaffective disorder if they exhibit features of both schizophrenia and a mood disorder, but the features do not strictly meet the diagnostic criteria for either alone (Miller & Black, 2019). Patients have psychosis which manifests in hallucinations, delusions, disorganized thinking and speech, and bizarre inappropriate motor behavior. Schizoaffective disorder is a presumptive diagnosis based on the client’s presenting with psychotic features (auditory hallucinations) and depression symptoms like feeling down, low energy, insomnia, loss of motivation, diminished pleasure, and difficulty concentrating.

Generalized Anxiety Disorder (GAD): GAD presents with increased, uncontrollable, and unwarranted anxiety and worry about various activities or events, presenting more days for at least six months. The diagnostic criteria for GAD require the presence of excessive worry/anxiety in addition to two of the following features: Restlessness or a keyed-up feeling, easy fatigue, difficulty concentrating, disturbed sleep, irritability, and muscle tension (DeMartini et al., 2019). The client reports always feeling anxious and worried, which suggests an anxiety disorder. In addition, she has GAD symptoms like concentration difficulties, distractibility, and sleeping disturbance. However, the patient’s depressive and psychotic symptoms made GAD a less likely primary diagnosis.

Major Depression: Depression is a mood disorder that causes feelings of sadness and a loss of interest in previously enjoyable activities. Other key features in the diagnostic criteria include appetite changes, sleeping difficulties, increased fatigue, slowed movements/speech, feelings of guilt, concentration difficulties, and suicidal ideations/thoughts (Christensen et al., 2020). The client presents with depression symptoms like feeling down, low energy, loss of motivation, sleep difficulties, loss of pleasure, feeling worthless and hopeless, and difficulty concentrating. However, the client also has psychotic features (auditory hallucinations), which rule out Major Depression as a primary diagnosis.

Reflection

In a similar patient assessment, I would measure the severity of the patient’s anxiety and depressive symptoms using mental health screening tools. For instance, I would use the Generalized Anxiety Disorder 7-item (GAD-7) to measure the severity of the patient’s anxiety symptoms and the Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms (Christensen et al., 2020). The client’s neighborhood and environment (where she lives, learns, works, and plays) greatly impact her overall health. Exposure to lead, infections, drug substances, and childhood trauma increases the risk of schizoaffective disorder and can result in poor health outcomes (Shim & Compton, 2020). Health education for this client should focus on medication adherence. The clinician should also involve the family and educate them on each medication’s benefits, risks, adverse effects, and alternatives to the drug (Cullen et al., 2020). This can promote better health outcomes and reduce the chances of relapse.

References

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

Cullen, B. A., Rodriguez, K., Eaton, W. W., Mojtabai, R., Von Mach, T., & Ybarra, M. L. (2020). Clinical outcomes from the texting for relapse prevention (T4RP) in schizophrenia and schizoaffective disorder study. Psychiatry Research, 292, 113346. https://doi.org/10.1016/j.psychres.2020.113346

 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

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of clinical Psychiatry : Official Journal of the American Academy of Clinical Psychiatrists, 31(1), 47–53.

Shim, R. S., & Compton, M. T. (2020). The social determinants of mental health: psychiatrists’ roles in addressing discrimination and food insecurity. Focus, 18(1), 25-30. https://doi.org/10.1176/appi.focus.20190035

BUY A CUSTOM- PAPER HERE ON; Comprehensive Psychiatric Evaluation Essay

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare
• Review this week’s Learning Resources and consider the insights they provide.
• Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain
• Then, based on your evaluation of this patient, develop a case presentation that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
Subjective:
• What details did the patient provide regarding their personal and medical history?
• What are their symptoms of concern?
• How long have they been experiencing them, and what is the severity?
• How are their symptoms impacting their functioning?
Objective:
• What observations did you make during the interview and review of systems?
Assessment:
• What were your differential diagnoses?
• Provide a minimum of three (3) possible diagnoses.
• List them from highest to lowest priority.
• What was your primary diagnosis, and why?
Reflection notes:
• What would you do differently in a similar patient evaluation?
• Reflect on one social determinant of health according to Healthy People 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider,
• what are one health promotion activity and one patient education considerations for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

• Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

CASE INFORMATION BELOW:

CC (chief complaint): “I can’t sleep at night, anxiety and pain in my chest. I keep hearing things”.
HPI:
The client is a 39-year-old white female who is here for an annual psychiatric evaluation. She has had past mental health Major Depressive Disorder, Generalized anxiety disorder (GAD), and schizoaffective disorder. She is currently taking Vraylar, Seroquel, Trazodone, Prazosin, Diazepam, and Propranolol. She currently rates her depression as an 8/10 with symptoms of feeling down, low energy, loss of motivation (LOM), loss of pleasure (LOP), and difficulty concentrating for greater than 4 years. She stated that she can’t concentrate in group settings, is easily distracted. She reports feeling anxious all the time and always worrying. She has racing thoughts, + mood fluctuations, + auditory hallucinations (AH), denies visual hallucinations (VH), and + paranoia (suspicious). No evidence of mania or delusions. She denies any inpatient hospitalization. When her mental health was at its worse, she reported that she couldn’t get out of bed, didn’t wash, and had feelings of helplessness and hopelessness, and worthlessness and that she is an embarrassment to her family. She denies past suicidal attempts. No current or recent SI or HI. No history of self-harm and she has a trauma history of physical, sexual, and emotional abuse. She is unable to go into detail about her trauma. She reports having night terrors and flashbacks. She has a therapist that she sees weekly. No current safety issues. Previous medications she tried included Buspar, Lexapro, Prozac, Paroxetine, Celexa, Zoloft, Effexor, Risperdal, Neurontin, and Abilify she reports were all ineffective.
Columbia suicide scale: 1-no 2-no
Substance Current Use: Denies.
Medical History: HTN, Chronic back, and neck pain (Followed by Cardiologist)
• Current Medications: Norvasc 5mg, Hyzaar 100mg-12.5mg, and Metoprolol 25mg
• Allergies: No known drug allergies (NKDA) and no known food allergies (NKFA).
• Reproductive Hx: 2 SVDs (2011 and 2015)
Family Psychiatric/Substance Use History:
The client denies a past psychiatric history on her maternal and paternal sides of the family. One younger brother with no mental health issues.
Psychosocial History:
The client is a 39-year-old female born in Russia and relocated to New Hampshire at the age of 21. She came to Camden, DE, in 2016. She grew up in a home with both parents, she has one younger brother. She is married and takes care of her husband who is a disabled veteran and 3 children. Her parents recently moved into the home to help take care of her 3 children. Her parents are very supportive. Her relationship with her husband and children is good. Her highest level of education graduated with a bachelor’s degree. She currently does not have any hobbies. She is currently mentally disabled and is financially stable with her disability. She has no past legal history or current issues. Positive history of trauma previously noted and currently no safety issues.
ROS:
• GENERAL: Negative for fever, chills, weight gain/loss, and positive for low energy.
• HEENT: Negative for blurred vision, eye pain, ear pain/discharge, hearing loss, nasal discharge, sneezing, or sore throat.
• SKIN: Negative for rash, discoloration, or bruises.
• CARDIOVASCULAR: Positive for chest pain, and palpitations no edema.
• RESPIRATORY: Negative for sob, cough, sputum, or chest pain that is respiratory-related.
• GASTROINTESTINAL: Negative for nausea, vomiting, epigastric pain, or bowel changes.
• GENITOURINARY: Negative for dysuria, or urinary frequency/urgency.
• NEUROLOGICAL: Negative for headache, dizziness, fatigue, muscle weakness, tingling sensations, and +pain in the neck.
• MUSCULOSKELETAL: Negative for muscle pain, joint stiffness, or joint pain.
• HEMATOLOGIC: Negative for bleeding and bruising.
• LYMPHATICS: Negative for enlarged lymph nodes.
• ENDOCRINOLOGIC: Negative for sweating, cold/heat intolerance, excessive thirst, hunger, or urine production.
Vital Signs: Temp- 98.6; P- 92; R-18; BP-144/88; Ht-5’1; Wt-138lbs
Diagnostic results: There are currently no test results available.
Mental Status Examination:
Female client in her late 30’s. She is AAOx3 but appears anxious. She is well-groomed and cooperative. She is dressed appropriately. She maintains good eye contact during the visit, has normal motor activity, and uses facial expressions appropriately. The self-reported mood is anxious, and the affect is appropriate. Her speech is clear with normal volume and tone, she has a logical and goal-directed thought process. There was no evidence of delusions and is having + auditory hallucinations, denies visual hallucinations, obsessions, or suicidal ideation/thoughts. Her short- and long-term memories are intact, his concentration is fair, and she possesses good judgment.
NEED 3 DIFFERENTIAL DX
PLEASE INCLUDE:
• Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
• Objective: What observations did you make during the interview and review of systems?
• Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
• Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to Healthy People 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education considerations for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.