Comprehensive Psychiatric Evaluation and Patient Case Presentation Essay

Comprehensive Psychiatric Evaluation and Patient Case Presentation Essay

Comprehensive Psychiatric Evaluation and Patient Case Presentation Essay

CC: “Homeless and depressed.”

HPI: M is a 45-year-old male who presents to the clinic because of problems with homelessness and depression. M had no depression until his mother and grandmother died successively in 2021, leaving him homeless. He starts fights and experiencing anger control issues because of his depression. Additionally, he has shut down as he does not feel like talking to people anymore. He is withdrawn, isolated, has low energy, and has crying episodes. These events have not affected his sleep. He is on unknown depression medication.

Past Psychiatric History:

• General Statement: M developed depression because of major life events, the death of his mother and grandmother in a span of 4 months. They were his support system. He does not have any other close family or friends for social support.
• Caregivers (if applicable):
• Hospitalizations: No hospitalization due to psychiatric issues
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: Past use of Marijuana/PCP/Cocaine use in the past, no current use. No history of ETOH and Tobacco. Last incarceration four years ago for cocaine use, released in 2018

Family Psychiatric/Substance Use History: Uncle, Father, Mother with un-named psych issues

Psychosocial History: he has four children, three girls and one boy. M’s highest level of education is contemporary. He lost his job four years ago and has been surviving on a disability check. He lives at his grandmother’s house but faces eviction this summer.

Medical History:

Current health issues: CHF, SOB, Pacemaker, back disk hernias, sleeps in a chair as he cannot breathe lying flat, cannot take steps, minimal mobilization due to pain needs assistive devices for ambulation, “Can hardly walk.”

• Current Medications: not known
• Allergies: Banana, NKDA

• Reproductive Hx:

ROS:

• GENERAL: denies recent weight loss or gain, feels low energy and fatigued, not headache or dizziness.
• HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
• SKIN: No rash or itching.
• CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
• RESPIRATORY: No shortness of breath, cough, or sputum.
• GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
• GENITOURINARY: Urination, urgency, color, and odor normal.
• NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
• MUSCULOSKELETAL: When walking, stiffness, limited mobility.
• HEMATOLOGIC: No anemia, bleeding, or bruising.
• LYMPHATICS: No enlarged nodes. No history of splenectomy.
• ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
  

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Physical exam:

Vital Signs: BP-120/76; HR-76; RR-20; Temp-98.4.

Diagnostic results: No diagnostic tests ordered.

Assessment

Mental Status Examination:

M is alert and oriented to time and place. The patient’s dressing is appropriate for the occasion, but grooming is concerning. His attention and concentration are good; he spells the word calendar forward and backward and can count backward. Spatial orientation is intact, but he seems to be having issues with motor coordination, including movement difficulties, retardation, and being easily agitated. His speech is clear, coherent, with appropriate volume. The mood is appropriate, but the affect is flat. His thoughts are organized and well presented, memory recall is good, and abstract reasoning is also fine.

M has had thoughts of self-harm but no attempt at self-harm or suicide. The patient is sometimes paranoid with auditory hallucinations, the latest one last month when he heard his mother’s voice advising him to “stay in the house and stay out of trouble”. No visual hallucinations or illusions. The patient feels hopeless, isolated, withdrawn, and low energy. He had not have a history of depression until recently when he experienced major life events leaving him homeless and without a support system. His symptoms are consistent with depressive disorder.

Differential Diagnoses:

Primary diagnosis:

Major Depressive Disorder (MDD) – MDD is a mood disorder characterized by feelings of sadness or low mood and loss of interest in activities that a person used to enjoy. According to the DSM-5, diagnosis of depression is confirmed by the presence of five or more of the following symptoms, where one of them must be either low mood or loss of interest, or both (Tolentino & Schmidt, 2018). The symptoms are loss of interest, depressed mood, insomnia/hypersomnia, weight gain or loss, increased/decreased appetite. The second criterion for diagnosing MDD is that the symptoms must not be associated with drug-related issues or any other mental health or medical conditions. Finally, the clinical presentations must cause significant impairment on one’s ability to work and function. Similarly, hallucinations, suicidal ideation, and instances of self-harm are may also be experienced by a person with depression (Hasin et al., 2018). M experiences several symptoms, including depressed mood, loss of energy/interest, hopelessness, withdrawal, and other issues causing significant impairment to his life.

Differential diagnosis

Bipolar disorder – Bipolar disorder is also a mood-based disorder characterized by two phases, the depressive phase and the mania/hypomania phase. In the depressive phase, the patient becomes sad, loses interest, and has feelings of guilt, among other depressive symptoms (Abrams, 2022). During the mani phase, one becomes full of energy and engages in creative activities, dangerous thrill-driven habits, and can go without sleep for one week. M experienced some symptoms of the depressive phase, but the manic symptoms are absent, making this diagnosis unlikely.

Borderline Personality Disorder (BPD) – BPD is instability in relationships and self-image characterized by fear of abandonment, impulsivity, extreme emotional swing, and a tendency for self-harm (Bozzatello et al., 2021).

Reflections:

The case presents a complex situation of mental illness, disability, homelessness, and physical health issues that further complicate the patient’s condition and coping abilities. I think the assessment is comprehensive, and I would do the same. In addition, I would seek to find the patient’s file regarding the previous visits to know the medications and other treatments prescribed. I would evaluate the patient’s response to pharmacology therapy to establish efficacy and safety. From this case, I learned the complex intersection between mental health, physical health, and the social system. The patient, in this case, needs social assistance with housing and home medical aid to assist with activities of daily living; they also need constant medical monitoring by a cardiologist and pulmonologist to enhance health outcomes. Thus, the intervention requires the involvement of an interprofessional team.

Similarly, patient education on medication management and adherence would be essential and health promotion related to physical activity and proper nutritional intake. While working with the patient, I will consider patient factors that define their cultural background. I will use the information to design a culturally appropriate intervention to enhance fairness and equity in care provision. Other ethical and legal issues that will inform my decisions include risk and benefit analysis of medications to prevent avoidable harm due to adverse events (Bipeta, 2019). Finally, I would refer the patient to a social worker to connect him with housing and other socioeconomic resources according to his needs.

References

Abrams, Z. (2022). Diagnosing and treating bipolar spectrum disorders. American Psychology Association, 53(1), https://www.apa.org/monitor/2022/01/ce-bipolar-spectrum.

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19.

Bozzatello, P., Garbarini, C., & Rocca, P. (2021). Borderline Personality Disorder: Risk Factors and Early Detection. Diagnostics , 11(11), 2142; https://doi.org/10.3390/diagnostics11112142.

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. (2018). Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA Psychiatry, 75(4), 336–346. https://doi.org/10.1001.

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 Criteria and Depression Severity: Implications for Clinical Practice. Frontiers in psychiatry, 9, 450. https://doi.org/10.3389/fpsyt.2018.00450.

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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 5 weeks, using the Comprehensive Psychiatric Evaluation Template provided.
To Prepare
Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has.
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.
Develop a presentation, based on your progress note 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.
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?
Rubric
Description of chief complaint and history of present illness
5 (5%) – 5 (5%). The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
Description of past psychiatric, substance use, medical, social, and family history
5 (5%) – 5 (5%). The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.
Discussion of most recent mental status exam and observations made during interview and review of systems
14 (14%) – 15 (15%). The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.
Discussion of diagnostics with results
9 (9%) – 10 (10%). The student provides an accurate, clear, and complete discussion of diagnostics with results.
Diagnosis with three (3) differentials
23 (23%) – 25 (25%). The student provides an accurate, clear, and complete diagnosis with three (3) differentials.
Comprehensive Psychiatric Evaluation documentation
23 (23%) – 25 (25%)
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.