Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Essay

 Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Essay

Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Essay

Subjective:

CC (chief complaint): The client has been depressed and anxious lately

HPI: Mrs. F. R, a 78-year-old female, came to the clinic complaining of increased depression and anxiety. She complains of sadness, crying, difficulty falling asleep, decreased appetite, lack of concentration, and tearfulness. Her anxiety symptoms include restlessness, fidgeting, and irritability. Other symptoms include chest tightness, poor concentration, feeling overwhelmed, brain fog, and is worried about making mistakes due to these symptoms. The patient states that these symptoms have worsened over the last few days. The patient has a bipolar 2 disorder history, presenting with both hypomania and depressive symptoms. Her condition was well-managed with Clonazepam 1mg PO PRN, Seroque 50mg, and lamotrigine 200mg. Her medications are no longer effective against the symptoms, and she worries about making mistakes.

Past Psychiatric History:

• General Statement: The has a positive history of bipolar 2 disorder which has been well-controlled until recently
• Caregivers (if applicable): No caregivers
• Hospitalizations: The patient has no history of hospitalization and denies homicidal or suicidal ideations or behaviors.
• Medication trials: Escitalopram, Buspirone, Latuda, Viibryd
• Psychotherapy or Previous Psychiatric Diagnosis: Anxiety and bipolar 2 disorder

Substance Current Use and History: Denies current or past substance use

Family Psychiatric/Substance Use History: Her son was diagnosed with depression

Psychosocial History: The client was born and raised by her parents in Media, PA. She has two siblings, a sister and a brother. In childhood, she lost her childhood friend and went through a traumatic period with no emotional support from her family. At that time, she started a fundraiser for CHOP, raising over 2 million dollars. She is divorced and has two sons. She did not remarry, but a partner passed after being together for 12 years. She was a reading specialist. One of her granddaughters was diagnosed with type 1 diabetes in August, and the client has been depressed and anxious lately. She feels she provides insufficient support compared to what she should.

Medical History:

• Current Medications: Seroquekl, Clonazepam, and Lamotrigine
• Allergies: No known drug or food allergies

• Reproductive Hx: Identifies as heterosexual and has two sons. She denies current or past STDs

ROS

General: Patient denies any recent weight gain or loss, fever, chills, weakness or fatigue. However, she reports changes in appetite and

HEENT: Head: Denies any recent trauma or headaches. Eyes: Denies recent visual changes, pain, drainage, itchiness, or dryness. Ears: Denies auditory changes, pain, ear ringing, or balance changes. Nose: Denies congestion, drainage, or sinus pain. Mouth/Throat: Denies pain swallowing, bleeding gums, or sputum production. Has lost some teeth.

Skin: Denies rashes, lesions, loose skin, dryness, itching, or lumps

Cardiovascular: The patient denies palpitation, chest pain, discomfort, or edema (peripheral or central)

Respiratory: Patient reports dry cough and denies shortness of breath, difficulty breathing, or fast breathing

Gastrointestinal: The patient denies constipation, diarrhea, vomiting, and abdominal pain. She reports changes in appetite

Genitourinary: Denies pain micturition, urgency, hesitancy, or changes in urine color or odor

Neurological: Denies dizziness, syncope, headaches, tingling sensations in the extremities, or bowel changes

Musculoskeletal: Denies joint, muscle, or back pain or stiffness

Hematologic: Denies easy bruising or uncontrollable bleeding

Lymphatics: Denies lymphadenopathy or history of splenectomy

Endocrinologic: Deniesheat or cold intolerance, sweating, excess thirst, or excess hunger

Physical Exam

Vital/: BP:134/86 left arm. P:73 regular T: 97 RR: 18

 Objective:

Diagnostic results: Not Applicable

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Assessment: Adjustment Disorder

Mental Status Examination: The patient has dressed accordingly, is well groomed and appears her states age. She has a pleasant attitude and collaborates throughout the interview. ASje reports having a depressed and anxious mood, and her affect is constricted and congruent. Thoughts are coherent, goal-directed, and logical. She denies auditory, tactile, or visual hallucinations or illusions. Denies suicidal ideations or tendencies. Her attention and concentration span are low, and her immediate recall and retention of recent and remote memories are intact. She has fair judgment and good insight into her problem. The patient reports changes in appetite (decreased) and difficulty sleeping (insomnia).

Differential Diagnoses:

Adjustment Disorder With Mixed Depressed and Anxious Mood

Adjustment disorder is diagnosed in patients with significantly stressful circumstances. The stressful circumstances are overwhelming and include loss of life, previous diagnosis, or changes in personal relationships, which cause much stress that the individual cannot cope with. Symptoms of the condition include anxiety, anhedonia, depression, hopelessness, decreased appetite, insomnia, anger, loss of appetite, and suicidal thoughts (O’Donnell et al., 2019). The disorder is common in patients with preexisting mood disorder problems and causes hopelessness and sadness. It can be easily confused with anxiety and depressive disorders due to the close;y similar presentations. The disorder can be associated with either depression or anxiety characteristics or both. According to the DSM-5, adjustment disorder is diagnosed when patients present with behavioral or emotional instability secondary to the particular life stressor, which develops within 3 months of the stressor, and the changes caused must be clinically significant (APA, 2022). These symptoms should also not meet the criteria for other disorders, are not part of the normal grieving processes, and do not last beyond six months after the event (APA, 2022). The DSM-5 criteria also note that an individual must present with anxiety and depression symptoms to be diagnosed with the mixed-type condition. The client reports increased anxiety and depression and identifies that the symptoms began when her granddaughter was diagnosed with diabetes. She feels she cannot take her granddaughter like she wants to help. The patient meets the criteria for this condition; hence it is the primary diagnosis.

Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder is being overly stressed about things or situations for no apparent or specific reason. DeMartini et al. (2019) note that the condition affects a significant percentage of the US population, with more females than males being victims. GAD is non-specific, and individuals with the condition often worry too much about general issues such as school and work. Patients feel out of control over routine activities and current situations. They are often worried about future unforeseen events. The DSM-5 describes GAD as excessive constant worry, occurring most days for at least six months (APA, 2022). The worry is often uncontrollable and must present with at least 3 or more symptoms among restlessness, easy fatiguability, difficulty concentrating, irritability, muscle tension, and sleep disturbance (APA, 2022). The patient presents with a majority of these symptoms, such as restlessness and irritability, and her symptoms cause significant clinical significance. However, her symptoms are attributable to an identifiable specific cause (her granddaughter was recently diagnosed with diabetes), which has not persisted for more than six months, ruling out the differential.

Major Depressive Disorder (MDD)

Major depressive disorder is a condition characterized by persistent and pervasive low mood. The condition significantly affects the individuals’ performance of activities of daily living and quality of life. Greenberg et al. (2021) note that major depressive disorder is a burdensome disorder with high healthcare costs and poor quality of life. According to the DSM-5, the patient must present with at least or more major depressive episodes and at least 5 symptoms among a depressed mood, anhedonia, significant weight changes, and sleep disturbance (APA, 2022). Other criteria include psychomotor agitation, fatigue, feelings of worthlessness, diminished cognitive abilities such as thinking, concentration, and decision-making, and suicidal thoughts (APA, 2022). The patient presents with helplessness, hopelessness, insufficiency in supporting her granddaughter, sadness, tearfulness, fidgeting, and poor concentration. However, the patient does not meet the diagnostic criteria for MDD.

Reflections: Comprehensive patient assessment is crucial to help develop a definitive diagnosis and inform care delivery and patient management. The assessment and diagnosis of this patient were thorough, but minor future improvements are necessary. For this patient’s case, I would give more attention to the patient’s medical records, psychiatric history, and family background. Comprehensive history gives clues as to what may be wrong with a patient and facilitates care interventions (Wheeler, 2020). The information would help understand the patient’s presentation and any familial predisposition for a definitive care plan. During the session, we thoroughly reviewed the patient with the preceptor, and I agree with the preceptor’s assessment findings. The diagnosis was based on the DSM-5 criteria, the globally accepted method of diagnosing psychiatric illnesses (APA, 2022). The diagnosis was also based on the presenting symptoms, which were also used to eliminate the differentials.

Case Formulation and Treatment Plan

Mrs. F. R., a 78-year-old female, presents to the clinic with anxiety and depression complaints. She is a bipolar 2 disorder patient under medications who recently experienced increased sadness, crying, tearfulness, insomnia, restlessness, irritability, fidgeting, poor appetite, and decreased concentration. She also presents with chest tightness and brain fog and feels she makes more mistakes due to these presentations.

During the patient’s management, it was essential to ascertain that there were no underlying conditions hence the need for tests such as thyroid stimulating hormone, BMP, and complete blood count. The recommended care interventions are the continuation of previous medications, which are clonazepam, Seroquel, and lamotrigine and the initiation of cognitive behavioral therapy. Cognitive behavioral therapy helps patients deal with disabling internal thought processes and is thus integral to managing mental health disorders (Wheeler, 2020). CBT decreases the patient’s anxiety and depression symptoms. CBT can be used alongside anxiety and depression medication to help improve the interventions’ effectiveness and promote better patient outcomes. Scheduling a meeting after two weeks and then every month to reevaluate the patient’s progress and any need for a change of healthcare interventions. These follow-up clinics help reassess patients and ensure patients receive the care due and

 I confirm that the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek-approved clinical site during this quarter’s course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).  https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

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

Greenberg, P. E., Fournier, A. A., Sisitsky, T., Simes, M., Berman, R., Koenigsberg, S. H., & Kessler, R. C. (2021). The economic burden of adults with major depressive disorder in the United States (2010 and 2018). Pharmacoeconomics, 39(6), 653-665. https://doi.org/10.1007/s40273-021-01019-4

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International Journal Of Environmental Research And Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537

Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing Company.

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Week (enter week #): (Enter assignment title)

Student Name
College of Nursing-PMHNP, Walden University
PRAC 6645: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date

Subjective:
CC (chief complaint):
HPI:
(include psychiatric ROS rule out)
Past Psychiatric History:
• General Statement:
• Caregivers (if applicable):
• Hospitalizations:
• Medication trials:
• Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:

• Current Medications:
• Allergies:
• Reproductive Hx:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
Case Formulation and Treatment Plan:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________
Date: ________________________

References