NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template

NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template

NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template

Patient Case Presentation

Subjective:

CC (chief complaint): “My mother thinks that I am stubborn”

HPI: K.J is a 16-year-old Caucasian male who was accompanied to the clinic by his mother claiming that he is very stubborn and out of control. The patient is agitated by simple things which make him angry and aggressive like when he is served cold food. At school, his teacher claimed that he is very stubborn, bullying the juniors, which led to him being suspended twice within 3 months. He disobeys his parents most of the time, leaving the house against their restrictions. The patient’s mother is worried that he might end up on the opposite side of the law, which may lead to him being imprisoned. The patient denies delusion, nightmares, delirium, or hallucinations.

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Past Psychiatric History:

• General Statement: The patient is stubborn, and has been suspended from school twice for bullying his juniors.
• Caregivers (if applicable): The patient is the only child, raised by a single mother, after the death of his father 2 years ago in a road accident.
• Hospitalizations: No history of hospitalization.
• Medication trials: Denies taking any medication for the current symptoms, or previous psychiatric disorder.
• Psychotherapy or Previous Psychiatric Diagnosis: No history of mental illness diagnosis or taking part in counseling.

Substance Current Use and History: The patient reports sneaking around once in a while to take alcohol and smoke marijuana with his friend, ever since the death of his father. He however denies cigarette smoking or use of any other recreational drug of abuse.

Family Psychiatric/Substance Use History: Mother with a history of depression, diagnosed after the death of her husband. Denies family history of substance use or any other mental disorder.

Psychosocial History: The patient is an only child, raised by a single mother, after the death of his father in a car accident. They live in a two-bedroom apartment downtown. His mother manages the family business downtown. The patient reports riding a bicycle for exercise every evening. He confirms sleeping well most nights. He however sometimes dreams about his father, which brings back sad memories. The patient has been suspended twice from school for bullying others. 

Medical History:  The patient is asthmatic, and he uses his Ventolin inhaler PRN.

• Current Medications: Ventolin inhaler 2 puffs PRN for the treatment of the patient’s asthmatic condition.
• Allergies: No known drug, food, or environmental allergies.

• Reproductive Hx: The patient is heterosexual. Reports being sexually active but with a single partner. Denies history of HIV or STIs.

ROS:

• GENERAL: Appears healthy with no distress. No weakness, fatigue, constipation, diarrhea, anxiety, or depression.
• HEENT: Head: No headache or signs of trauma. Ears: No tinnitus, inflammation, tenderness, exudates, itchiness, or hearing loss. Eyes: No excessive tearing, blurred vision, redness, itchiness, double vision, night blindness, or use of corrective lenses. Nose & Throat: No running nose, nose bleeding, sinusitis, congestion, itchiness, or inflammation. Denies toothache, bleeding gums, or swallowing difficulties.
• SKIN: Warm and moist with no rashes, hives, itchiness, redness, or lumps.
• CARDIOVASCULAR: No chest pressure, palpitations, cyanosis, arrhythmias, paroxysmal nocturnal dyspnea, claudication, or peripheral edema.
• RESPIRATORY: No wheezing, running nose, congestion, chest tightness, breathing difficulties, sputum production, sore throat, or sneezing.
• GASTROINTESTINAL: No abdominal distension, tenderness, constipation, diarrhea, hernia, or nausea and vomiting.
• GENITOURINARY: No hesitancy, urgency, or burning on urination. Denies having a history of genitourinary disorders.
• NEUROLOGICAL: No headache, ataxia, dizziness, numbness, changes in bowel or bladder control, tingling in the extremities, or syncope.
• MUSCULOSKELETAL: Exhibits full range of movement in all the body joints, with no difficulties. Denies muscle and joint tenderness, stiffness, or swelling.
• HEMATOLOGIC: Denies bruising easily. No anemia, nose bleeding, or any other hematological disorder.
• LYMPHATICS: Denies history of lymphadenopathy or splenectomy.
• ENDOCRINOLOGIC: No polyuria, polyphagia, polydipsia, or heat or cold intolerance.

Physical exam:

Vital Signs: T 97.4, BP 137/86, HR 97, R 18, OS 99%, Ht 69, Wt. 185.6.

Diagnostic results: Routine blood work was ordered, including complete blood count, hemoglobin, and white blood cells to assess for signs of infection or other medical conditions. A comprehensive metabolic panel was also ordered comprising Creatinine, ALP, ALT, AST, and Bilirubin. Additional tests ordered include LFTs, kidney function tests, prolactin levels, electrolyte levels, and prolactin levels. Urine and blood screening for drugs was also ordered to develop a differential diagnosis. Additional screening tools were administered including the Patient Health Questionnaire (PHQ) and Mood Disorder Questionnaire (MDQ) (Freitag et al., 2018).  

Assessment

Mental Status Examination: The 16-year-old walks to the examination room confidently in age-appropriate casual clothes. He is alert and well-oriented in both time and place and person. He looks energetic but with mild distress. His speech is fluent, but with a fluctuating volume. He is reluctant to answer some questions, with a short concentration span. He responds rudely to some questions, displaying some level of anger. His thought process is consistent with his age. His memory is intact, with unremarkable intellectual capacity. His mood is sad. He denies hallucination, delusion, suicidality, or nightmares.

Differential Diagnoses:

1. Conduct Disorder: According to the DSM-V this disorder is usually diagnosed in patients who are 17 years and below. The criteria require the patient to display violent and unacceptable behavior at the community level, which undermines the privileges of others. To qualify for this diagnosis, a patient must present with not less than 6 of the following symptoms for at least 6 months; stealing, bullying, disobeying elders, violent behavior, engaging in fights, skipping school, and responding rudely to elders (Fairchild et al., 2019). The patient is positive for all of the above symptoms, which qualifies CD as the primary diagnosis.
2. Oppositional defiant disorder: The DSM-V requires the patient to present with symptoms of anger, irritability, argumentative, defiant behavior, and vindictiveness for at least 6 months to qualify for this diagnosis (Gunes et al., 2018). The patient is positive for stubbornness, and anger. However, he also presents with additional symptoms like bullying others, which makes conduct disorder more applicable as compared to ODD.
3. Substance use disorder: According to the DSM-V criteria SUD is characterized by excessive use of a substance despite the negative effect that the substance has on the patient’s life (Masroor et al., 2019). The patient reports using marijuana and drinking alcohol with friends but only occasionally. The drugs might have contributed to his symptoms, but does not qualify for a SUD diagnosis.

Reflections: The patient in the provided case study displays stubborn behavior which suggests the possibility of conduct disorder. The PMHNP did an excellent job of acquiring adequate information to support this diagnosis. However, interviewing the patient’s friends and teachers would have been very beneficial in acquiring first-hand data on the patient’s behavior at school and in social places (Freitag et al., 2018). However, the patient being a minor leaves the mother with legal rights to make decisions concerning his health. As such, the clinician should ask the mother for permission before taking such actions. Consequently, the patient’s mother must be adequately informed about the patient’s medical condition and available treatment options, to help them take part in deciding on the most effective treatment plan.

Case Formulation and Treatment Plan:  

Primary Diagnosis: Conduct Disorder

Psychotherapy: Cognitive behavioral therapy is recommended as the first choice for the management of conduct disorder, with a great focus on developing problem-solving skills and strengthening social relationships (Eskander, 2020).

Pharmacotherapy: The use of medication is only considered an adjunct to CBT. Selective serotonin reuptake inhibitors, such as Zoloft are recommended to help manage patient symptoms like depression (Eskander, 2020).

Health Promotion: Getting enough rest, and exercising will help the patient focus more energy on developing himself rather than being stubborn (Freitag et al., 2018). Getting enough sleep also helps reduce the patient’s stress levels.

Patient Education: The patient should be educated on the importance of complying with the treatment plan for positive outcomes (Eskander, 2020). The patient mother should be advised on appropriate self-care actions to help promote appropriate behavior for her child.

Follow-up: The patient should report back to the clinic after 2 weeks for evaluation of the treatment outcome.

 References

Eskander, N. (2020). The Psychosocial Outcome of Conduct and Oppositional Defiant Disorder in Children With Attention Deficit Hyperactivity Disorder. Cureus, 12(8). https://doi.org/10.7759/cureus.9521

Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W. E., Odgers, C. L., Franke, B., Freitag, C. M., & De Brito, S. A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1). https://doi.org/10.1038/s41572-019-0095-y

Freitag, C. M., Konrad, K., Stadler, C., De Brito, S. A., Popma, A., Herpertz, S. C., Herpertz-Dahlmann, B., Neumann, I., Kieser, M., Chiocchetti, A. G., Schwenck, C., & Fairchild, G. (2018). Conduct disorder in adolescent females: current state of research and study design of the FemNAT-CD consortium. European Child & Adolescent Psychiatry, 27(9), 1077–1093. https://doi.org/10.1007/s00787-018-1172-6

Gunes, H., Tanidir, C., Adaletli, H., Kilicoglu, A. G., Mutlu, C., Bahali, M. K., Topal, M., Bolat, N., & Uneri, O. S. (2018). Oppositional defiant disorder/conduct disorder co-occurrence increases the risk of Internet addiction in adolescents with attention-deficit hyperactivity disorder. Journal of Behavioral Addictions, 7(2), 284–291. https://doi.org/10.1556/2006.7.2018.46

Masroor, A., Patel, R. S., Bhimanadham, N. N., Raveendran, S., Ahmad, N., Queeneth, U., Pankaj, A., & Mansuri, Z. (2019). Conduct Disorder-Related Hospitalization and Substance Use Disorders in American Teens. Behavioral Sciences, 9(7), 73. https://doi.org/10.3390/bs9070073

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Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last 2 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient