Comprehensive Psychiatric Evaluation- Differential Diagnosis and Primary Diagnosis Formulation

Comprehensive Psychiatric Evaluation- Differential Diagnosis and Primary Diagnosis Formulation

Subjective

ID: The patient, Fatima Branning, is a 28-year-old female. She visited the clinic after a recommendation by her boss, Mr. Nehring.

CC (chief complaint): “Mr. Nehring wants to fire me.”

HPI: Branning is a 28-year-old female who presented to the clinic with complaints that her boss wants to fire her from her job. She notes that her supervisor is in love with her but wants to fire her, as his love for her is getting in the way. She adds that despite her supervisor being in a relationship, he is lustful. Her perception of the supervisors’ lust and love for her include her being given easier assignments, being asked to voice her opinions in meetings and the way he walks towards her. Branning notes that she is beautiful, boastful, strong, and attracts people with her strength. This makes her boss and supervisor threatened and thereby gang up against her. There have been no instances of sexual harassment from the supervisor despite her firing claims. Reports also indicate that she has not had any sales in the past three weeks, something she attributes to a slow period. She considers suing her supervisor and manager for discrimination, under the stress and health problems she has had.

Past Psychiatric History:

• General Statement: No reports of any psychiatric illnesses. There are also no reports of any accidents, head injuries, or past surgeries.
• Hospitalizations: No reports of any past hospitalizations.
• Medication trials: No reports of past medication use.
• Psychotherapy or Previous Psychiatric Diagnosis: No reports of past psychotherapy or any psychiatric diagnosis.

Substance Current Use and History: No reports of alcohol or tobacco use. There are also no reports of the use of illicit substances and narcotics.

Family Psychiatric/Substance Use History: No reports of mental health issues within the family. There are also no reports of substance use in the family.

Psychosocial History: The patient was raised by her parents as the only child in Coronado (CA). She works as an administrative assistant in car sales. She is in a relationship.

Medical History: The patient has a medical history of scoliosis. She is currently under chiropractic care.

Current Medications: No reports of current medication use.

Allergies: The patient is allergic to latex.

Reproductive Hx: The patient has regular menses.

ROS

• GENERAL: No reports of recent changes in weight, fever, chills, or fatigue.
• HEENT: No reports of head injuries, hearing loss, discharge, or ear infections. There were also no reports of visual loss, double vision, blurred vision, or recent eye infection. No reports of recent anosmia, nasal tenderness, or discharge. There were also no reports of difficulty in swallowing or sore throat.
• SKIN: No reports of unusual skin dryness, discoloration, swelling, scarring, scaling, or abnormal thickening.
• CARDIOVASCULAR: No reports of palpitations, chest pain, or swelling in the extremities.
• RESPIRATORY: No reports of wheezing, troubled breathing, coughing, or excessive mucus production.
• GASTROINTESTINAL: No reports of bowel movement inconsistencies.
• GENITOURINARY: No reports of urinary frequency, urgency, hesitancy, or dysuria.
• NEUROLOGICAL: No reports of recent headaches, dizziness, syncope, or seizures.
• MUSCULOSKELETAL: No reports of muscle stiffness, muscle pain, or restriction in the movements of the joints.
• HEMATOLOGIC: No reports of easy bleeding, bruising, or anemia.
• LYMPHATICS: No reports of swelling in the lymph nodes or splenectomy.
• ENDOCRINOLOGIC: No reports of excessive sweating, cold intolerance, or diabetes.

Objective:

Physical Exam:

• Physical examination is negative except for paranoia.
• Vital signs: T- 98.4 P- 82 R 18 124/74 Ht 5’0 Wt 118lbs

Diagnostic results: Not applicable.

Assessment:

Mental Status Examination: The patient is alert and oriented to place time, and event. She is also responsive to the questions asked and aware of her surroundings. Her speech is normative in volume and tonation. She seems anxious. Her thought processes are illogical as her beliefs and perception of her situation are erotomanic. Her memory is intact, as she can recall events at her workplace. Her judgment is goal-directed and logical. Her effect is euthymic. The patient seems to have delusional thought processes. No reports of hallucinations or suicidal ideations and attempts.

Differential Diagnoses:

• Delusional Disorder

Delusional disorder is a mental health illness characterized by a fixed false belief about something based on an inaccurate exposition of an external reality despite evidence of the contrary. Patients with the delusional disorder will commonly manifest with multiple non-bizarre situations and false beliefs on some aspects of social functioning that cannot be explained by another underlying factor (González-Rodríguez & Seeman, 2022). In the case presented, the patient seems to be delusional. She has a fixed belief that her supervisor is in love with her despite being in a relationship. Likewise, her interpretations of actions that surmount love may not be interpreted by others as love. She also demonstrates bizarre delusions, as her thoughts are not consistent with reality. This warranted the inclusion of this differential.

• Schizophreniform Disorder

Schizophreniform disorders are mental health illnesses characterized by delusions, psychosis, hallucinations, and disorganized speech (Wright, 2020). This differential was included due to the presence of delusionary behaviors in the patient case above. It was, however, ruled out due to the absence of psychotic manifestations and hallucinations.

• Bipolar Disorder/Depression

Bipolar and depressive disorders are common mental health illnesses. Delusions are common manifestations of mood disorders (Rodriguez et al., 2023). This warranted the inclusion of this differential. They were, however, ruled out since they did not meet the criteria for depressive disorders and bipolar.

Reflections: The case presented is highly suggestive of a delusional disorder. Delusional disorder is a clinical diagnosis that is made upon assessing subjective and objective findings from the patient (Raihani & Bell, 2019). In this case, this diagnosis was arrived at after eliminating other conditions that can possibly present with delusionary behaviors.

References

González-Rodríguez, A., & Seeman, M. V. (2022). Differences between delusional disorder and schizophrenia: A mini-narrative review. World Journal of Psychiatry, 12(5), 683–692. https://doi.org/10.5498/wjp.v12.i5.683

Raihani, N. J., & Bell, V. (2019). An evolutionary perspective on paranoia. Nature Human Behaviour, 3(2), 114–121. https://doi.org/10.1038/s41562-018-0495-0

Rodriguez, K. M., Sharifi, V., & Eaton, W. W. (2023). Association of psychotic experiences and incident depression in a longitudinal population‐based community survey. Psychiatric Research and Clinical Practice, 5(1), 16–23. https://doi.org/10.1176/appi.prcp.20220021

Wright, M. (2020). Schizophrenia and schizophrenia spectrum disorders. JAAPA, 33(6), 46–47. https://doi.org/10.1097/

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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?

Comprehensive Psychiatric Evaluation- Differential Diagnosis and Primary Diagnosis Formulation

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.).
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