NRNP-PRAC 6635 Comprehensive Psychiatric Evaluation

NRNP-PRAC 6635 Comprehensive Psychiatric Evaluation

WEEK 7: Assessing and diagnosing patients with schizophrenia, other psychotic Disorders, and Medication-Induced Movement Disorders.

Subjective:

CC (chief complaint): The patient started acting different or sort of strange way, having thoughts and hearing things that other people cannot hear or see. Her roommates think she lives in a movie.

HPI: Ms. J.S. is a 28-year-old female who presented to a clinic for psychiatric evaluation after her roommates noticed that she has been having thoughts and hearing things that others cannot hear or see. This is after the patient’s younger brother committed suicide in front of her via GSW after his girlfriend broke up with him, which occurred 12 days ago. The patient’s roommates were concerned about her change of behavior and brought her to the clinic. The patient says that her roommates think she is living in a movie, and she is being listened to by Russian men and hoes who send messages by drilling. She says that she has neighbors who are Russians who speak with code and lie about being Spanish. She hears them speaking, and her roommates cannot hear in coded language; she goes to her car so that Russians cannot code here. She thinks that her neighbors are terrorists who are looking for blueprints and that she can prevent that from happening using markers. She has thoughts of hurting her roommates.

Past Psychiatric History:

• General Statement: The patient has been on alprazolam which she was prescribed 1mg twice daily as needed by her PCP for 15 days, but she stopped taking them.
• Caregivers (if applicable): Her two roommates were concerned about her behavior.
• Hospitalizations:  No history of being admitted or undergoing any treatment or medications.
• Medication trials: The patient has not been in any form of medication trials.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has never been diagnosed with any psychiatric issues in the past and has not sought any attention regarding psychotherapy services.

Substance Current Use and History: The patient has smoked cannabis since she was 16 and takes a couple of drinks of beer, as reported by her roommates, but she claims not to be taking any alcohol or substance abuse.

Family Psychiatric/Substance Use History: No history of drug or substance abuse in the family or any person within the family with a psychiatric condition.

Psycho-social History: The patient works as a bartender and has two roommates. She has smoked cannabis on a daily basis since she was 16, goes out on weekdays 2–3 times with her roommates, and has a couple of drinks of beer. Additionally, the patient is estranged from her parents, and her brother was her only sibling. She is only sleeping 1–2 hours/24hrs.

Medical History:

• Current Medications: No current use of medications because she reports refusing to continue with her prescription alprazolam 1mg twice daily as needed by her PCP for 15 days.
• Allergies: No history of any allergies reported by the patient, but currently only taking canned foods.
• Reproductive Hx: No history of any reproductive issues or complaints.

ROS:

• GENERAL: No weight loss, fever, chills, weakness, or fatigue
• HEENT: Eyes: No visual loss and no blurred vision. Ears, nose, and throat: Hearing is intact, with no congestion, no running nose, or any sore problems.
• SKIN: No rush or any itching.
• CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
• RESPIRATORY: No shortness of breath, cough, or sputum. The patient reports difficulty catching their breath when anxious.
• GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
• GENITOURINARY: No burning on urination, urgency, hesitancy, odor, odd color
• NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
• MUSCULOSKELETAL: No muscle or back pain, joint pain, or stiffness.
• 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. However, she experiences sweating when anxious.

Objective:

Physical exam: Not applicable

Diagnostic results: Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Chen., (2017).

Imaging such as a CT scan and MRI to rule out any brain injury due to self-harm not mentioned by the patient.

Assessment:

Mental Status Examination:

The patient is a 28-year-old female who matches her age, is well-dressed and groomed, and her speech is clear. The patient appears anxious or scared and seems uneasy. She does not seem calm and relaxed. She keeps on holding the pillow and touching her hands while speaking with the doctor. Expressing herself in some questions seems to upset or remind her of something she does not want to speak about. She is very confident in what she is saying despite her roommates saying otherwise and feels that no one understands her. She does not want to disclose her upbringing or confirm what her roommates are saying by acting in some way.

Differential Diagnoses

Delusional Disorder: According to the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-5), delusional disorder is defined as a disease marked by delusions for at least one month but no other psychotic symptoms (Peralta & Cuesta, 2019). Delusions are false ideas that persist despite evidence to the contrary and are not shared by other members of the person’s society or subculture. Persecutory delusions (belief that one will be harmed by an individual, organization, or group), referential delusions (the belief that gestures, comments, or environmental cues are directed at oneself), grandiose delusions (the belief that the individual has exceptional abilities, wealth, or fame), and erotomanic delusions (the belief that another individual is in love with them) are all examples of delusions, nihilistic (the belief that a huge catastrophe will occur) or somatic (the notion that a major catastrophe will occur) (i.e., beliefs focused on bodily function or sensation) (González-Rodríguez, 2020). Delusional disorder is referred to as “partial psychosis” in the literature because the cognitive organization and reality testing are otherwise intact. The individual with the delusional disorder has a variety of paranoid beliefs, but they are usually not odd and are not accompanied by any other schizophrenia symptoms. Since the patient is experiencing a series of things that other people surrounding her are not able to see or think. She thinks her neighbors are Russians and terrorists, which can be realistic or not. On the contrary, her neighbors are not Russians but Spanish. The patient even thinks they have blueprints which can be unrealistic.

Bipolar Disorder: Bipolar disease, also known as bipolar disorder or manic-depressive illness (MDI) in the ICD-10, is a prevalent, severe, and long-term mental illness. This is a dangerous condition that will affect you for the rest of your life. It is characterized by times of deep, continuous, and profound depression that alternate with periods of mania, which is characterized by an overly high or agitated mood (Rowland, 2018). Manic episodes last at least one week and are marked by elation, anger, or expansiveness. Hypomanic episodes last about four days and are marked by an elevated, expansive, or irritated mood. The difference is that these symptoms in hypomania are not severe enough to hinder social or vocational functioning or warrant hospitalization, and they are not linked to psychosis. The patient’s expression seems to be showing swift emotions because of what she thinks and imagines and a progression of depression, which can make it a probable diagnosis.

Depression: Depression (major depressive disorder) is a common and significant medical condition that has a negative impact on how you feel, think, and behave. It is also, thankfully, treatable. Depression produces unhappiness and/or a loss of interest in previously appreciated activities. It can cause a number of mental and physical issues, as well as a reduction in your capacity to operate at work and at home (LeMoult & Gotlib, 2019). A person’s grief might be exacerbated by the death of a loved one, the loss of a career, or the termination of a relationship. It’s natural to experience melancholy or grief in response to such circumstances. Those who have suffered a loss may describe themselves as “depressed.” The patient’s pattern of sleep might be showing that she is depressed due to the loss of her brother, who was her only sibling, which may suggest that she may be undergoing depression due to bereavement.

Reflections:  I agree with the preceptor’s assessment and diagnostic impression of the patient, though there needs to be more or more information on the patient’s history on family, drug and substance abuse, and her family history just to be more accurate and close to the diagnosis. Schizophrenia seems to be the most appropriate diagnosis for the patient because of what she is experiencing, how she responds to questions asked, and what her roommates think of her. The roommates should be educated on the condition of the patient and how to handle the patient.

References

Chen, Y. L., Shen, L. J., & Gau, S. S. F. (2017). The Mandarin version of the Kiddie-Schedule for Affective Disorders and Schizophrenia-Epidemiological version for DSM–5–A psychometric study. Journal of the Formosan Medical Association, 116(9), 671-678. https://doi.org/10.1016/j.jfma.2017.06.013

González-Rodríguez, A., & Seeman, M. V. (2020). Addressing Delusions in Women and Men with Delusional Disorder: Key Points for Clinical Management. International Journal of Environmental Research and Public Health, 17(12), 4583. https://doi.org/10.3390/ijerph17124583

Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic advances in psychopharmacology, 8(9), 251-269. https://doi.org/10.1177%2F2045125318769235

LeMoult, J., & Gotlib, I. H. (2019). Depression: A cognitive perspective. Clinical Psychology Review, 69, 51-66. https://doi.org/10.1016/j.cpr.2018.06.008

Peralta, V., & Cuesta, M. J. (2019). An empirical study of five sets of diagnostic criteria for delusional disorder. Schizophrenia Research, 209, 164-170. https://doi.org/10.1016/j.schres.2019.04.02.

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NRNP-PRAC 6635 Comprehensive Psychiatric Evaluation

Psychotic disorders and schizophrenia are some of the most complicated and challenging diagnoses in the DSM. The symptoms of psychotic disorders may appear quite vivid in some patients; in others, symptoms may be barely observable. Additionally, symptoms may overlap among disorders. For example, specific symptoms, such as neurocognitive impairments, social problems, and illusions, may exist in patients with schizophrenia but are also contributing symptoms for other psychotic disorders.

For this Assignment, you will analyze a case study related to schizophrenia, another psychotic disorder, or a medication-induced movement disorder.

To Prepare:

• Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing psychotic disorders. Consider whether experiences of psychosis-related symptoms are always indicative of a diagnosis of schizophrenia. Think about alternative diagnoses for psychosis-related symptoms.
• Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also, review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
• By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
• Identify at least three possible differential diagnoses for the patient.

NRNP-PRAC 6635 Comprehensive Psychiatric Evaluation