Comprehensive Psychiatric Evaluation Essay
CC (chief complaint): ‘I am so anxious when around people.’
HPI: Kennedy is a 31-year-old male that has been admitted to the unit for treatment for the past 10 weeks due to alcohol, pcp, and marijuana abuse. The patient has a diagnosis of bipolar disorder and post-traumatic stress disorder and is currently undergoing treatment. The client reports that the accompanying symptoms when he is around people include stomach upset, sweating, and a racing heart. He also feels paranoid that people are talking about him and out to get him. As a result, he isolates himself. He also reports hearing voices that tell him to do bad things. He reports sleep problems that include nightmares. His energy levels are on and off. He also gets emotional outbursts and anger sometimes. He has thoughts of self-harm without a plan. His appetite changes since it is a time good and bad sometimes.
Past Psychiatric History:
- General Statement: ‘I am so anxious when around people.’
- Caregivers (if applicable): none
- Hospitalizations: This is the first hospitalization. There are no other histories of hospitalizations for mental health problems.
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: No history of psychotherapy. He has previous diagnoses of bipolar disorder and post-traumatic stress disorder.
Substance Current Use and History: The client has a history of alcohol, pcp, and marijuana abuse. No current history of abuse was given.
Family Psychiatric/Substance Use History: The client reports that his mother’s side has a history of anxiety, depression, and substance abuse.
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Psychosocial History: The client is single. He has a history of being picked up a lot and isolated when he was a child. He is not employed because of his disability. He is currently an unauthorized probation because of smacking someone in the door where he was locked up for 14 days.
- Current Medications: The patient is currently using Trazodone 150 mg, Prazosin 1 mg, Seroquel 50 mg, and Fluoxetine 40 mg.
- Allergies: No history of allergies
- Reproductive Hx: No history of sexually transmitted infections, increased urinary urgency, and pain during urination
GENERAL: The patient appeared appropriately dressed for the occasion. Absent upper arm tremors, severe or abnormal weight loss.
HEAD/NECK: The client denied lymphadenopathy, neck pain, rigidity, distended veins, and pain in swallowing.
EYES: The client denied vision changes, drainage, pain, or double vision. He does not use corrective lenses.
EARS/NOSE/MOUTH/THROAT: The patient denied changes in hearing, ear drainage, ear pain, and infections. He also denied nasal congestion, drainage, and nose bleeds. He denied halitosis, difficulties in swallowing, bleeding gums, sore throat, and sore tongue.
CARDIOVASCULAR: The client denied chest pain and palpitations.
PULMONARY: The client denied shortness of breath, cough, dyspnea, wheezing, and pleuritic pain.
GASTROINTESTINAL: He denied abdominal tenderness, constipation, diarrhea, and bloating.
GENITOURINARY: The client denied urinary incontinence, painful urination, increased frequency in urination, and abnormal smell of urine.
MUSCULOSKELETAL: The patient denied muscle pain, fractures, tenderness, and muscle weakness.
INTEGUMENTARY: The client denied rashes, lumps, bruises, and lacerations.
NEUROLOGICAL: He denied headache, dizziness, vomiting, and nausea. He experienced slurring of speech during the assessment.
PSYCHIATRIC: The client has a history of post-traumatic stress disorder and bipolar disorder.
ENDOCRINE: The client denied cold, heat intolerance, and changes in body weight as well as polyuria, polydipsia, and polyphagia.
HEMATOLOGIC/LYMPHATIC: The patient denied lymphadenopathy.
ALLERGIC/IMMUNOLOGIC: The client denied any history of food, drug, or environmental allergies.
Physical exam: if applicable
Diagnostic results: Diagnostic and laboratory investigations are essential to developing an accurate diagnosis for Kennedy. One of the recommended diagnostic investigations is thyroid function tests. Thyroid function tests are important to rule out thyroid disorders such as hyperthyroidism as the cause of symptoms that include lack of attention and insomnia. Blood tests should also be performed to rule out any infection. Tests such as complete blood count will enable the psychiatrists to initiate necessary treatments to treat any infection the patient might be having. There is also the need to perform diagnostic imaging of the brain to rule out pathologies such as tumors. The patient experiences symptoms such as increased agitation, emotional outbursts, and easy irritability, which may necessitate imaging studies to rule out any brain pathologies that may be contributing to the problem.
Mental Status Examination: Kennedy appears appropriately dressed for the occasion. He is oriented to self, others, time, and events. He does not demonstrate abnormal movements such as tics and tremors. Kennedy reports a recent experience of anxiety attacks. He also reports a history of delusions and auditory hallucinations. The patient notes a history of suicidal thoughts without a plan. He does not have a history of a suicide attempts. The thought process is future-oriented.
- Generalized anxiety disorder: The first primary diagnosis that should be considered for Kennedy is generalized anxiety disorder. Kennedy has symptoms that align with those associated with this disorder. According to DSMV, patients with generalized anxiety disorder experience symptoms that include excessive worry and anxiety about things. Excessive worry is often difficult for the patient to control. The accompanying symptoms of excessive worry and anxiety include restlessness, easy fatigability, impaired concentration, irritability, increased muscle aches, difficulty in sleeping, sweating, and palpitations (DeMartini et al., 2019). Kennedy has excessive worry and anxiety when with a group of people with some of the above accompanying symptoms, hence, generalized anxiety disorder is his primary diagnosis.
- Persecutory delusion: The other primary diagnosis that should be considered for Kennedy is persecutory delusion. Persecutory delusion is a mental health disorder characterized by the patient feeling that a person or a group of people want to hurt them. Patients believe that their perception is true despite lacking any proof. Persecutory delusion is common in patients diagnosed with post-traumatic stress disorder, schizophrenia, or schizoaffective disorder (Diaconescu et al., 2019). Kennedy has a history of being diagnosed with post-traumatic stress disorder. As a result, persecutory delusion should be considered as part of the primary diagnosis.
- Depression: The other secondary diagnosis to consider for Kennedy is depression. Depression is a mental disorder that is characterized by patients reporting depressed moods in almost all day, every day. The DSMV also asserts that patients with depression experience symptoms that include diminished interest or pleasure in activities most of the day almost every day, weight loss or gain, slowed thought process and physical activity, fatigue, feeling worthless, and difficulty in concentration. Patients also report recurrent suicidal thoughts, attempts, plans, and insomnia (Kraus et al., 2019). Kennedy has some of the symptoms associated with depression. He reports changes in his appetite, some experiences of lack of energy, and insomnia. Therefore, post-traumatic stress disorder is a secondary diagnosis that should be considered when developing a treatment plan.
- Post-traumatic stress disorder: The last differential diagnosis that should be considered for Kennedy is post-traumatic stress disorder. Post-traumatic stress disorder is diagnosed in patients having a history of direct or indirect traumatic experiences. Patients experience symptoms that include avoidance of any stimuli related to the trauma, flashbacks about the trauma, nightmares, and significant distress when exposed to the stimuli or trauma. Patients also experience additional symptoms that include the negative alterations in their cognition and mood-related to the traumatic event and alterations in reactivity and arousal associated with the trauma (Bryant, 2019). Kennedy has a traumatic experience during his childhood. He reports that other children always isolated him and always picked him up. Therefore, post-traumatic stress disorder should be considered a secondary differential for him.
Reflections: I believe that I developed an accurate diagnosis for Kennedy. I utilized evidence-based approaches in his assessment to develop the diagnosis. I also considered any factors that may be contributing to his current health status. Therefore, one thing that I would do should I encounter a similar patient in the future is to incorporate psychotherapy into the treatment process. Psychotherapy would help the patient to manage symptoms of generalized anxiety disorder and triggers of depressive symptoms (Strawn et al., 2018).
Bryant, R. A. (2019). Post-traumatic stress disorder: A state-of-the-art review of evidence and challenges. World Psychiatry, 18(3), 259–269. https://doi.org/10.1002/wps.20656
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
Diaconescu, A. O., Hauke, D. J., & Borgwardt, S. (2019). Models of persecutory delusions: A mechanistic insight into the early stages of psychosis. Molecular Psychiatry, 24(9), 1258–1267. https://doi.org/10.1038/s41380-019-0427-z
Kraus, C., Kadriu, B., Lanzenberger, R., Zarate Jr., C. A., & Kasper, S. (2019). Prognosis and improved outcomes in major depression: A review. Translational Psychiatry, 9(1), 1–17. https://doi.org/10.1038/s41398-019-0460-3
Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: An evidence-based treatment review. Expert Opinion on Pharmacotherapy, 19(10), 1057–1070. https://doi.org/10.1080/14656566.2018.1491966
Comprehensive Psychiatric Evaluation
Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis.
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.
Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
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 â€œnormalâ€ (rather than specific value). Abnormal results should be reported as a specific value.
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?
Description of chief complaint and history of present illness
Points Range:5 (5.00%) – 5 (5.00%)
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
Points Range:5 (5.00%) – 5 (5.00%)
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
Points Range:14 (14.00%) – 15 (15.00%)
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
Points Range:9 (9.00%) – 10 (10.00%)
The student provides an accurate, clear, and complete discussion of diagnostics with results.
Diagnosis with three (3) differentials
Points Range:23 (23.00%) – 25 (25.00%)
The student provides an accurate, clear, and complete diagnosis with three (3) differentials.
Comprehensive Psychiatric Evaluation documentation
Points Range:23 (23.00%) – 25 (25.00%)
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.