NRNP 6635 Week 11 Assignment: Comprehensive Psychiatric Evaluation and Patient Case Presentation

NRNP 6635 Week 11 Assignment: Comprehensive Psychiatric Evaluation and Patient Case Presentation

NRNP 6635 Week 11 Assignment: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Comprehensive Psychiatric Evaluation and Patient Case Presentation

Subjective:

CC (chief complaint): The 26 year-old male patient is presented to the hospital with a complaint of attempted suicide by overdosing on bupropion (Wellbutrin). The patient had been found by the housekeeping staff while unconscious in a bathrub in the hotel in which he was staying. He complains of “depression” and states that he is experiencing internal irritation “like I want to crawl out of my skin”.

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HPI: The patient has a past history of psychiatric illness and has attempted suicide before about sight months ago when he broke up with his boyfriend. The current symptoms started a few months ago, and he first noticed them eight months ago when he broke up with his boyfriend. His depressive and psychotic symptoms are present all day all the time and are characteristically persistent and repetitive. They are in his thoughts and are aggravated by loneliness (solitude) and sometimes relieved by company. The symptoms are not intermittent but constant and the historian rates them at 8/10.

Past Psychiatric History:

• General Statement: The patient has a history of psychiatrc illness for which he has been teated by among others bupropion 9wellbutrin). However, he does not seem to have gained any benefit from the interventions as the symptoms are still persistent. Sadness, solitude, and suicidality seem to be the most prominent of the symptoms.
• Caregivers (if applicable): He is dysfunctional interpersonally, occupationally, and in terms of self care. He needs a caretaker and currently he does not have one as he is not even in contact wth his birth parents.
• Hospitalizations: He has been hospitalized severally in the past with the last one being sight months ago. The hospitalizations do not sem to have benefited him in the lng term as the symptoms that include long-standing suicidality still persist.
• Medication trials: He has been tried on a number of medications for various diagnoses. The one that he overdosed with is bupropion or Wellbutrin, which is FDA-approved for major depressive disorder (MDD), seasonal affective disorder, and nicotine addiction. The medication is also given for bipolar depression, attention/ deficit-hyperactivity disorder (ADHD), and sexual dysfunction although it is not FDA-approved for these (Stahl, 2017).
• Psychotherapy or Previous Psychiatric Diagnosis: His likely previous psychiatric diagnoses may have included bipolar disorder, MDD, or seasonal affective disorder. This extrapolation is made from the fact that he had Wellbutrin with him and on which he attempted to overdose. Wellbutrin is a prescription-only medication.

Substance Current Use and History: The patient has a history of abusing prescription medications. For instance, he regularly abuses antidepressants and this is responsible for some of his symptoms such as feeling like crawling out of his skin. This is depersonalization and derealization.

Family Psychiatric/Substance Use History: There is no significant history of substance use in his immediate family, although some psychiatric history is present. He states that his father had episodes of “psychosis” frequenty and that his late grandfather had schizophrenia. The grandfather had been an alcoholic and smoker.

Psychosocial History: He is a 26 year-old transgender male who experienced traumatic events in his childhood. He had ben sexually abused as a child by his own father and brother. He does not have much educational achievement having dropped out of school in grade ten. Currently he is homeless and lives off the proceeds of prostitution. Presently he does not have a regular boyfriend after breaking up with the last one eight months ago.

Medical History:

• Current Medications: He is currently taking bupropion SR (Wellbutrin) 200 mg BID.
• Allergies: He has no known allergies with regard to medications, food, or other environmental allergens.

• Reproductive Hx: He is a transgender male who has never been married and does not have any children  

ROS:

• GENERAL: Denies fatigue, weight loss, fever, chills, or headache.
• HEENT: Denies photohobia, short-sightedness, and tearing. He also denies tinnitus, hearing loss, otorrhea, rhinorrhea, sneezing, and sore throat.
• SKIN: Negative for rashes and itching or eczema.
• CARDIOVASCULAR: Denies chest pains/ discomfort, palpitations, and edema.
• RESPIRATORY: Netagive for shortness of breath, wheezing, coughing, or producing phlegm.
• GASTROINTESTINAL: He is negative for nausea, vomiting, diarrhea, or an alteration in bowel habits.
• GENITOURINARY: He denies frequency of micturition, hesitancy, or incontinence.
• NEUROLOGICAL: Denies paraesthesia, syncope, loss of bladder and bowel control, paresis, or a tingling sensation.
• MUSCULOSKELETAL: He denies arthralgia and myalgia as well as joint stiffness.
• HEMATOLOGIC: Denies any blood and clotting conditions ithin his family.
• LYMPHATICS: There is no history of splenectomy and currently he experiences no lymphadenopathy.
• ENDOCRINOLOGIC: He denies ever having hormonal therapy, feeling excessively thirsty, or drinking a lot of water (polydipsia) in one go.

Objective:

Physical exam:

Vital signs: T 98.2° F; BP 120/70 mmHg; HR 68; RR 16; and BMI 24.6 kg/m² (normal weight).

General: The patient appears disheveled, suspicious, and paranoid. His speech is pressured and he keeps on fidgeting in his chair. His speech is clear but disjointed but still goal oriented. He is oriented in time, space, person, place, and event.

HEENT: Head is normocephalic and atraumatic. Pupils are both equal, round, and reacting to light and accommodation (PERRLA). The extraocular muscles are bilaterally intact (EOMI). His neck is supple with no cervical lymphadenopathy noted. Sclerae are unicteric and there is no tearing. Light reaction by nboth tympanic membranes is normal with no fluid level noted. They are not perforated on either side. The external auditory canal is clear of cerumen. The nasal turbinates are not inflamed and the nasal septum is medially placed. There is no rhinorrhea or polyps. The throat is not erythematous.

Cardiovascular: S1 and S2 are both audible on auscultation with no murmurs, bruits, or gallops.

Respiratory: The lung fields are clear bilaterally with no rhonchi, crepitations, wheezes, or rales.

Diagnostic results: The laboratory results indicate no physical illness. The Patient Health Questionnaire (PHQ-9) and the Beck Depression Inventory scores show that the patent has moderate to severe depression (Willacy, 2019).

Assessment:

Mental Status Examination: The patient is a 26 year-old Caucasian male who is unkempt in appearance. His speech is disjointed and not very clear, coherent, or logical. It is hyperverbal, disorganized, and pressured. He is however oriented in time, place, space, person, and event. He tilts his head from side to side very now and then but displays no other mannerisms or tics. His self-reported mood is “sad” and his affect is dysphoric, indicating that the two are indeed congruent. He does not deny that he occasionally hears voices and also states that he at times senses as hough he is outside his body (depersonalization/ derealization). He is paranoid and suicidal but shows no homicidal ideation. His insght and judgment are affected. The diagnosis made is that of schizoaffective disorder bipolar type, whose DSM-5 diagnostic code is 295.70 (F25.0) (APA, 2013; Sadock et al., 2015).

Differential Diagnoses:

1. Schizoaffective Disorder Bipolar Type

The presentation of this patient is closest to this disorder according to the DSM-5 diagnostic criteria. For this diagnosis to be made, there must be a major mood episode in a period of uninterrupted illness that is concurrent with criterion A of schizophrenia. There must also be depressed mood. Durng the duration of the condition there must also have been delusions or hallucinations for two orv more weeks in the absence of a major mood episode. Lastly, the symptoms or disturbance are not attributable all the time t the effects of a substance (APA, 2013; Sadock et al., 2015). This patient fulfils almost al of these criteria, even though he abuses antidepressants.

1. Major Depressive Disorder (MDD) with Psychotic Features

This is a plausible differential diagnosis for this patient. However, the psychotic features are more towards schizoaffective disorder than MDD. For ths reason, the former is preferred as the primary diagnosis and the latter can be ruled out.

1. Antidepressant-Induced Mania

This is the tthird plausible differential diagnosis and it is considered because the patient is a known abuser of antidepressants. However, the symptoms he has are so consistent that he would have to be continuously taking the antidepressants for them to remain obvious. It is fo this reason that this diagnosis is the keast likely.

Reflections: I conducted this assessment and interview as per recommended protocol and would do I the same way again (Carlat, 2017). I used evidence-based tests and assessment tools such as the PHQ-9 and the BDI-II and these were instrumental in confirming the nature of the diagnosis. Autonomy was preserved as the patient was asked for informed consent any test was used on him (Haswell, 2019). The line of questioning avoided causing him emotional and psychological distress in the spirit of nonmaleficence. Health education was offered on the measures that can be taken by the patient and the familily/ caregivers to prevent harm occurring to the patient or someone else. This included engaging the patient in different activities and encouraging him to exercise. Therapy was also suggested (Corey, 2017) in the form of group cognitive behavioral therapy (CBT) in which he would benefit from group therapeutic factors such as universality, catharsis, altruism, and nterpersonal learning.

References

American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Carlat, D.J. (2017). The psychiatric interview, 4^th ed. Wolters Kluwer.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10^th ed. Cengage Learning.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6^th ed. Cambridge University Press.

Willacy, H. (November 13, 2019). Screening for depression in primary care. https://patient.info/doctor/screening-for-depression-in-primary-care

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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.

To Prepare
Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Select a patient that you examined during the last 2 weeks who presented with a disorder other than the one present in your selected case for Week 5.
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. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Develop a video case presentation, based on your evaluation of this patient, 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.
Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
Assignment
Record yourself presenting the complex case for your clinical patient. In your presentation:

Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
Present the full case. Include 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.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:

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?