Comprehensive Psychiatric Evaluation

Patient Demographics

Initials: AB   Race: Caucasian     Age: 35      Gender: Male

CC (chief complaint): Agitated patient sent to the psychiatry facility for restoration of competency after arrest for possession and auto theft.

HPI: The patient is a 35-year-old Caucasian male who was brought to the psychiatric facility for restoration of competency because he was arrested for auto theft and possession. The patient was witnessed talking to himself and having auditory and visual hallucinations while refusing to bathe and flush his toilet in jail. Before coming to the clinic, the patient reported visions of God, and over the past few weeks, he believed he was Jesus Christ sent to save the world. He states that his wife was worried about this behavior and feared leaving him with their two children. He, however, states that everything was exaggerated, and he believes the television has told him that he is Jesus Christ, the son of God.

Past Psychiatric History:

• General Statement: The patient was hospitalized, aged 18, for substance abuse detox.
• Caregivers (if applicable): Not applicable.
• Hospitalizations: The patient has been hospitalized twice for schizophrenia. He was last hospitalized five years ago at the local psychiatry hospital. At the age of 18, he was hospitalized for substance abuse detox. The patient has a history of suicidal ideation. Denies any history of suicidal ideation.
• Medication trials: The patient has used Abilify 10mg for schizophrenia. He, however, stopped using this drug since it caused him to have sleep issues. He was up and down at night and nodded off during the day instead of working.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient reports talking to a psychiatrist but reports that he stopped going as soon as he started feeling better.

Substance Current Use and History: The patient reports drinking five bottles of beer a day and a packet of cigarettes. Reports using illicit substances such as cocaine and meth. Reports using marijuana and LSD. He denies any withdrawal effects, such as delirium, seizures, or tremors.

Family Psychiatric/Substance Use History: Father is alive with schizophrenia. His sister attempted suicide at the age of fifteen. My maternal aunt has a history of depression and anxiety disorders. My paternal grandfather has bipolar disorder.

Psychosocial History: The patient was born in New York and was raised by both parents. He is the eldest of three siblings, aged 25 and 20 years. Both siblings are females. The patient lives in the suburbs with his wife and two children. He has a master’s degree in business administration and owns a car dealership business. He loves reading the Bible and religious novels during his free time. The patient has a history of arrest due to auto theft and possession. Denies any childhood or adulthood trauma. Denies any history of violence.

Medical History:  All vaccination records are up to date. The patient denies any major childhood or adulthood illness.

• Current Medications: Denies any current medications
• Allergies: No known drug or food allergies

• Reproductive Hx: Uses condoms as a contraceptive. Has one sexual partner, who is his wife. Has oral and vaginal sex.

ROS:

• GENERAL: Denies fatigue, chills, weakness, or fever
• HEENT: Head: Denies headache or trauma. Eyes: Denies eye pain, vision loss, eye discharge, or use of lenses. Ears: Denies hearing loss, ear discharge, or ear pain. Throat: Denies sore throat or throat pain. Nose: Denies runny nose, nasal congestion, or sneezing.
• SKIN: Denies itching or rashes.
• CARDIOVASCULAR: Denies palpitations, peripheral edema, chest pain, chest discomfort, or chest pressure.
• RESPIRATORY: Denies sputum, cough, labored breathing, or wheezing.
• GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or abdominal pain.
• GENITOURINARY: Denies penile discharge, urinary hesitancy, odor, or incontinence.
• NEUROLOGICAL: Denies syncope, headache, ataxia, numbness, tingling sensations, paralysis, or changes in bladder control.
• MUSCULOSKELETAL: Denies joint pain, stiffness, back pain, or muscle pain.
• HEMATOLOGIC: Denies easy bruising, anemia, or bleeding.
• LYMPHATICS: Denies enlarged lymph nodes.
• ENDOCRINOLOGIC: Denies heat/cold intolerance, polyuria, polyphagia, or polydipsia.

Physical exam:

Constitutional: BP 129/110  Pulse Rate: 88 beats/min   Resp 19 cycles/min  Temp 97.2   Ht: 5’3”   Weight: 164 lbs   BMI: 23.4

General: The patient is appropriately dressed for the weather. He is cooperative and responds well to the questions.

HEENT: Head is atraumatic and normocephalic. Normal hair distribution. Eyes: Conjunctiva is clear with normal visual fields. PERRLA. Ear: Normal pinna shape with a patent auditory canal. TM is grey on both ears. Nose: Mucous membranes are moist with patent nasal nares. Throat: Moist oral mucosa that is non-erythematous. Tonsils are non-tender on palpation.

Integumentary: Breasts are non-tender with no masses. Skin is warm and moist to the touch. No visible tattoos or scars.

Cardiovascular: Chest deformity not noted. Jugular veins not engorged. No peripheral edema was noted. Cap refill < 3s.  S1 and S2 were heard with peripheral pulses present. No murmurs or carotid bruits heard.

Respiratory:  Normal chest movements. No labored breathing was noted. The chest expands equally bilaterally. No rhonchi, wheezing, or crackles were noted. Tactile fremitus equal.

Gastrointestinal: Bowel sounds normoactive and equal on four quadrants. No masses on papation. No hepatomegaly or splenomegaly. No rebound tenderness on deep palpations.

Musculoskeletal: Upper and lower limbs present. No muscle or bone tenderness. Normal joint movements with no stiffness.

Neurological: The patient is A &O X3. Cranial nerves are intact. Normal muscle tone in upper and lower extremities.Erect posture and normal gait. Brudzinki and Kerning signs negative.

Diagnostic results:

 Positive and Negative Syndrome Scale (PANSS)

PANSS is a medical scale for measuring the severity of schizophrenic symptoms. This scale is used in the study of antipsychotic treatment. It is considered the gold standard in assessing psychotic behavioral conditions (Leucht et al., 2019). It measures positive and negative symptoms. Positive symptoms include the excess of normal functions and delusions and hallucinations, while negative symptoms include the loss of normal functions (Vrbova, 2018). The patient scored 50% for positive symptoms, 30% for negative symptoms, and 50% for general psychopathology

Assessment

Mental Status Examination:

The patient is a 35-year-old Caucasian male who is alert and oriented to person, place, time, and event. He is appropriately dressed for the weather. He demonstrates no significant tics or gestures. The patient’s speech is slow and interrupted with silence at times. He reports a euthymic mood with a constricted affect. The client denies auditory or visual hallucinations but appears to be talking to someone. He has paranoid and delusional thought processes. His judgment and insight are impaired. The patient denies homicidal or suicidal ideation.

Differential Diagnoses:

Schizophrenia

The DSM-V diagnostic criteria must be fully met for an individual to be diagnosed with schizophrenia. The first criterion is the presence of delusions, hallucinations, disorganized speech, negative symptoms, and catatonic behavior for at least a month  (American Psychiatric Association, 2013). The patient has auditory hallucinations and believes he is Jesus Christ. The patient’s symptoms also have affected her interpersonal and self-care. The symptoms should be present for at least six months, and the disturbance should not be explained by physiological conditions (American Psychiatric Association, 2013). The patient meets all the diagnostic criteria, making this condition the primary diagnosis.

Brief Psychotic Disorder

Even though this disorder presents with symptoms similar to schizophrenia, it occurs for a shorter duration. The symptoms of a brief psychotic disorder are present for at least a month (Valdés-Florido et al., 2021). The patient has had these symptoms for years and was even stopped taking Abilify because of the sleep issues that it caused.

Delusional Disorder

Even though the patient was delusional and believed he was Jesus Christ. Delusional disorders can, however, be differentiated from schizophrenia. The delusional disorder does not present schizophrenic symptoms such as auditory or visual hallucinations, negative symptoms, catatonic behavior, and disorganized speech (Muñoz-Negro et al., 2017). This rules out this diagnosis.

Reflections

This case study was challenging to formulate. Schizophrenic patients may be difficult to handle since they present with catatonic behavior. I conducted a comprehensive patient history to help me narrow down the diagnosis. The PANNS score is a helpful diagnostic tool to help determine the severity of schizophrenia. I utilized evidence-based guidelines to help determine the diagnosis. The most important of all is the DSM-V diagnostic criteria, which help behavioral health professionals globally to diagnose mental conditions. If I were to do this again, I would separately interview the patient’s wife to help determine the severity of the situation.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Leucht, S., Barabássy, Á., Laszlovszky, I., Szatmári, B., Acsai, K., Szalai, E., Harsányi, J., Earley, W., & Németh, G. (2019). Linking PANSS negative symptom scores with the clinical global impressions scale: Understanding negative symptom scores in schizophrenia. Neuropsychopharmacology, 44(9), 1589-1596. https://doi.org/10.1038/s41386-019-0363-2

Muñoz-Negro, J. E., Ibáñez-Casas, I., De Portugal, E., Lozano-Gutiérrez, V., Martínez-Leal, R., & Cervilla, J. A. (2017). A Psychopathological comparison between delusional disorder and schizophrenia. The Canadian Journal of Psychiatry, 63(1), 12-19. https://doi.org/10.1177/0706743717706347

Valdés-Florido, M. J., López-Díaz, Á., Palermo-Zeballos, F. J., Garrido-Torres, N., Álvarez-Gil, P., Martínez-Molina, I., Martín-Gil, V. E., Ruiz-Ruiz, E., Mota-Molina, M., Algarín-Moriana, M. P., Guzmán-del Castillo, A. H., Ruiz-Arcos, Á., Gómez-Coronado, R., Galiano-Rus, S., Rosa-Ruiz, A., Prados-Ojeda, J. L., Gutierrez-Rojas, L., Crespo-Facorro, B., & Ruiz-Veguilla, M. (2021). Clinical characterization of brief psychotic disorders triggered by the COVID-19 pandemic: A multicenter observational study. European Archives of Psychiatry and Clinical Neuroscience. https://doi.org/10.1007/s00406-021-01256-w

Vrbova, K. (2018). Comorbidity of schizophrenia and social phobia – Impact on quality of life, hope, and personality traits: A cross-sectional study. Neuro Endocrinol Lett, 39(1), 9-18. https://doi.org/10.26226/morressier.5a7070e4d462b80290b566e1

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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 your Preceptor must initial each page. 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.

I will be doing a presentation, based on my progress note of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, and 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.