Comprehensive Psychiatric Evaluation – Analyzing Case Histories and Diagnoses

Comprehensive Psychiatric Evaluation – Analyzing Case Histories and Diagnoses

CC (chief complaint): Lisa comes to the hospital with complaints of refusal to go back to rehab and feeling scared.

HPI: Lisa is a 33-year-old female who is currently in the detox facility considering long-term rehab. Also, she expresses feelings of fear and distress related to her current situation. She reports that her fears started when she found that her boyfriend, Jeremy, had embezzled money from the business. Also, she says that she found her boyfriend cheating on her. She reports that Jeremy has been taking money from her personal bank accounts, buying cocaine, and paying his debts. She acknowledges that she tried cocaine which Jeremy made her try. She admits to abusing appropriates of about $100 daily, cannabis 1-2 times weekly, and ½ gallon of vodka daily. Lisa acknowledges that she needs help with her drug problem but she is at the same time scared of going to rehab and says that she does not need help because her boyfriend said she has no problem. She is fearful that if she goes back to rehab she will not be able to get a job.

Past Psychiatric History:

General Statement: The patient has a history of substance abuse of cocaine, alcohol, and cannabis. She has a history of childhood trauma at the age of 6 to 9 years.

Caregivers (if applicable): the mother lives in Maine and has a history of benzodiazepine abuse and agoraphobia. Her elder brother has a history of opioid use and has had no contact with the family in the last 10 years.

Hospitalizations: She reports she has not been hospitalized before following a mental condition and this is her first admission.

Medication trials: She has no other history of medications.

Psychotherapy or Previous Psychiatric Diagnosis: Lisa reports no previous psychiatric diagnosis or psychotherapy.

Substance Current Use and History: Patient reports using opioids for about $100 daily, cannabis 1-2 times weekly using a medical card, and alcohol (1/2 gallon of vodka daily). Also, she has a positive screen for THC and opioids.

Family Psychiatric/Substance Use History: The patient has a positive substance use history in the family. The mother has a history of agoraphobia and benzodiazepine abuse while the brother has a history of opioid use. The father has a history of drug abuse that led to his arrest.

Psychosocial History: the patient is estranged from the father and has a history of childhood abuse by the father at the age of 6-9 years. She currently stays in a rented place away from her previous home with her boyfriend. She caught her boyfriend cheating with someone else, resulting in distress to leave the relationship. However, later she allowed him back to her life after asking for forgiveness. The patient reports loss of money in a business venture with Jeremy and ongoing issues with his boyfriend’s use of cocaine.

Medical History:

Current Medications: None.

Allergies: Allergic to azithromycin.

Reproductive Hx: The patient reports having one daughter who lives with some friends and is heterosexual.

ROS:

GENERAL: The patient has not reported any signs of fatigue, weakness, or weight loss. The patient sleeps 5-6 hours, reports reduced appetite, and prefers to get high overeating.

HEENT: No runny nose, sinus pain, sneezing, sore throat, or bleeding gums reported. No difficulty or pain swallowing or hearing loss was reported.

SKIN: reports no skin rash, skin irritation, or wounds.

CARDIOVASCULAR: Reports not feeling any discomfort or chest pain. No claudication, palpitations, or edema noted.

RESPIRATORY: No coughing, sneezing, shortness of breath, or sputum production.

GASTROINTESTINAL: Has no bloody stools or abdominal pain, no flu or nausea reported. No change in bowel movements or diarrhea symptoms was noted.

GENITOURINARY: Denies increased urination hesitancy, urgency, or burning. No alteration in color. Odorless, polydispsic, and polyuric in nature.

NEUROLOGICAL: No dizziness, headaches, syncope ataxia, lightheadedness, paralysis, ataxia, or tingling or numbness in the extremities or limbs were reported.

MUSCULOSKELETAL: No complaints of muscle or joint pain or muscle stiffness were reported.

HEMATOLOGIC: No bruising or bleeding was reported.

LYMPHATICS: No hx of splenectomy reported. Lymph nodes are normal with no swelling.

ENDOCRINOLOGIC: Normal thyroid glands in shape, size, and structure.

Objective:

Physical exam: The patient was cooperative. Vitals were taken. Appeared distressed throughout the interview.

Diagnostic results: Lisa’s admission lab results show abnormal liver function tests (ALT 168, AST 200, ALK 250, bilirubin 2.5, and albumin 3.0) and a positive urine drug screen of THC and opioids. TEMP- 100.0F, Pulse- 108 beats/minute, RESP- 20 breaths/ min, BP-180/110 mmHg, Height- 5’6 ft, Weight 146lbs.

Assessment:

Mental Status Examination: The 33-year-old American female appears to be of the age she claims and is dressed appropriately for the weather. She is not accompanied by anyone. She appears distressed and worried. She is well dressed, groomed, and looks presentable/ she maintains eye contact and is cooperative all through the interview. No abnormal motor behaviors are seen. Her speech is coherent. She claims to be feeling scared, which is congruent to her affect; she looks worried and in distress. Has no acute psychosis, no delusions nor suicidal thoughts, no hallucinations. She denies any thoughts of harming other people. Her immediate, recent, and long-term memory are intact. The patient has partial insight, for she acknowledges that she needs help but at the same time claims to be well and not addicted.

Pertinent positive: Family history of drug use and mental illness and the history of childhood trauma, decreased appetite, sleep disturbance, abnormal liver function tests, results, positive urine drug screen for opiates and THC, and history of drug use including cannabis, alcohol, and opiates.

Pertinent negative: No hallucinations, no suicidal thoughts, no illusions, and no delusions.

Differential Diagnoses:

Substance Use Disorder: Lisa has a history of substance abuse, including cannabis, opioids, and alcohol. Her daily use of opioids, together with daily alcohol intake, points out a possible substance use disorder (National Institute of Mental Health, 2023).

Post-Traumatic Stress Disorder: Lisa’s history of trauma in childhood, where her father sexually abused her, may have resulted in PTSD. PTSD is mainly associated with past trauma history that triggers anxiety symptoms (Schrader & Ross, 2021). Symptoms like distress, fear, avoidance of specific situations like rehab, and hypervigilance may point to PTSD (Bryant, 2019).

Major Depressive Disorder (MDD): Lisa reports feelings of fear and distress. Also, symptoms of sleep disturbance and reduced appetite are consistent with MDD (Karrouri et al., 2021). The presence of anxious distress further complicates her manifestation and suggests a mood disorder like MDD.

Primary diagnosis: The primary diagnosis is substance use disorder, which is the most prominent given Lisa’s case. Her history of daily cannabis use, opioid use, alcohol use, and recent use of cocaine is in line with the DSM-5-TR criteria for Substance Use Disorder. This diagnosis describes Lisa’s pattern of impaired control, social impairment, and substance abuse, which are the main causes of her presenting issues(National Institute of Mental Health, 2023).

Reflections:

Upon reflecting on the case, it is important that Lisa be approached with empathy, understanding the difficulty of her struggles and the interactions of predisposing factors, including interpersonal relationships, substance abuse, and trauma. Also, I would aim to build rapport and trust with Lisa, address her resistance and fears about rehab, and, at the same time, underscore treatment benefits.

From a legal and ethical point of view, I would consider upholding patient autonomy whereby the patient has a right to make their own decision about the treatment they choose to receive (Olejarczyk & Young, 2022). Given that Lisa chooses not to go to rehab, her choice should be respected. However, Lisa should be counseled about the importance of going to rehab and using collaborative efforts to empower her to participate actively in her care, nurturing a sense of accountability and ownership. When conducting health promotion and disease prevention, I would consider Lisa’s age, trauma history, previous history of drug use, and solving any conflict of interest with her relationship with Jeremy. I would employ a holistic approach that addresses all these factors. Health promotion would include encouraging addiction recovery support, mental health management, and relapse prevention strategies. Disease prevention would involve offering resources for counseling, therapy, and support groups to address the history of drug abuse, trauma, and her relationship with Jeremy.

References

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

Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated treatments and future challenges. World Journal of Clinical Cases, 9(31), 9350–9367. https://doi.org/10.12998/wjcc.v9.i31.9350

National Institute of Mental Health. (2023). Substance use and co-occurring mental disorders. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health#:~:text=Substance%20use%20disorder%20(SUD)%20is

Olejarczyk, J. P., & Young, M. (2022). Patient rights and ethics. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538279/

Schrader, C., & Ross, A. (2021). A review of PTSD and current treatment strategies. Missouri Medicine, 118(6), 546–551.

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

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. Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis.

Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rule out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).