NRNP-PRAC 6635 Comprehensive Psychiatric Evaluation Template

NRNP-PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): The patient is a 36-year-old male who was brought to the hospital with restlessness, agitation, rapid and disorganized speech, and impaired cognitive ability. The patient also had periodic symptoms of delusions. The family report revealed that the patient has been feeling out of touch and has consistently mentioned non-existent things. They also reported that he keeps forgetting things.

HPI: The patient has been experiencing the reported symptoms for a varied duration. Collaborative history reveals an alternating occurrence of on and off episodes of mood for close to three weeks before the date of presentation. The family mentioned that the on-episodes are characterized by agitation and restlessness and often last a few hours. The off episodes are usually long and are characterized by a lack of motivation and withdrawal. The symptoms of impaired cognitive ability, delusions, and hallucinations have been occurring periodically and have lasted four weeks by the time of presentation.

Past Psychiatric History:

General Statement: The patient has been on bipolar medications for ten years. He has, however, not been adherent to the prescribed medication and often finds excuses to avoid taking medications. The patient has also been on treatment for schizophrenia since his 30th birthday.

Caregivers: The patient was placed under a caretaker nurse upon his initial diagnosis of schizophrenia. Caretaker recommendations were later lifted by his psychiatrist six months after commencing antipsychotic medications.

Hospitalizations: The patient has been hospitalized once since being diagnosed with schizophrenia. This hospitalization was attributable to an attempted suicide that saw him overdose on his antipsychotic medications.

Medication trials: Upon diagnosis of schizophrenia, this patient was started on fluphenazine decanoate 2.5mg OD. The patient first reported positive results with the use of this medication but later complained of diminished sexual drive and constant constipation that was not adequately relieved by constipation medications. Upon review of the treatment, the drug choice was revised to the medications he is currently on.

Psychotherapy or Previous Psychiatric Diagnosis: The patient was diagnosed with bipolar disorder ten years ago. He was since placed on mood stabilizers and reported a positive prognosis thereafter. The patient has, however, registered multiple recurrences of bipolar symptoms lately. This has been attributed to poor medication-taking behavior, as evident in medication non-compliance. At 27 years, suspicion of psychotic episodes was first registered in the patient. Differentials, however, ruled out a possible diagnosis of schizophrenia since a nexus was made between the occurrence of the episodes and substance abuse. The patient was, however, hospitalized for two weeks and was started on short-term antipsychotic medications.

Substance Current Use and History: The patient has a significant history of substance abuse. He reports being a binge alcohol drinker and a frequent smoker of cigarettes and cannabis since his undergraduate years but ceased after being diagnosed with schizophrenia. He admits to being an active cigarette smoker and occasional alcohol drinker.

Family Psychiatric/Substance Use History: The family history of the patient reveals that the patient’s paternal grandfather died of schizophrenia. Additionally, the family exhibits a clear pattern of drug use, with all members of his paternal family being cigarette smokers and alcohol drinkers.

Psychosocial History: The patient was born 34 years ago in Cleveland, OH, and later relocated his family to Oakland, CA, where he still lives. He was the last born into a family of five. He has two brothers and two sisters who are all still alive. Her parents are still married and live together in Cleveland. All of his parents are healthy and have no known history of chronic disease. He has a wife and one 5-year-old daughter. The patient is a software engineer who runs a small enterprise in Oakland. He likes reading books and traveling. The patient has been involved in multiple counts of violence, one of which led to his hospitalization and consequent arrest. A legal pursuit on the matter revealed that he was guilty of assault and was sentenced to two years of imprisonment at a correctional facility in Cleveland.

Medical History: The medical history of the patient is significant for multiple hospitalizations. At 23 years old, during his graduation ceremony, the patient was involved in violent conduct that saw him sustain multiple head injuries. He was, however, discharged upon complete recovery. Another significant hospitalization came when he was involved in a minor car accident that was preceded by a house party. He sustained minor injuries and was treated at a local outpatient department. The patient was also hospitalized for malaria that he contracted when he visited an African country during his undergraduate course.

Current Medications: The patient is currently on sodium valproate 500mg BD, sertraline 20mg PO 6 hourly, alprazolam 1mg OD, and aripiprazole 15mg OD.

Allergies: The patient has no known allergies to any of the medications he is currently taking.

Reproductive Hx: The reproductive history of the patient reveals that the patient is a heterosexual who is married and has one child. He currently reports no sexual irregularity except when he was on fluphenazine medications. Collaborative history from the wife reveals that the patient is sexually active but is sometimes withdrawn, especially when his symptoms erupt.

ROS:

GENERAL: The patient has significant evidence of weight gain, with the wife reporting that he has gained close to 2 pounds in two weeks.

HEENT: Examination of the eye reveals visual acuity with no notable visual changes. The patient also has auditory acuity with no evidence of throat discomfort, running nose, or sneezing.

SKIN: Examination on the skin reveal a warm to touch skin, with regular skin alignment and good skin turgor, as well as an absence of abnormal skin pigments.

CARDIOVASCULAR: Cardiovascular examination reveals regular chest alignment with no notable chest discomfort and absence of palpitations. The patient has a blood pressure of 135/86 and a pulse rate of 80bpm.

RESPIRATORY: Respiratory exam reveal regular chest movement with no evidence of shortness of breath or labored breathing. The examination also revealed an absence of cough or sputum production and regular chest sounds.

GASTROINTESTINAL: Examination revealed normal bowel sounds with no evidence of nausea, vomiting, or anorexia. There was also no evidence of tenderness or abdominal swelling.

GENITOURINARY: Examination revealed regular urination with no urinary frequency, urgency or discomfort.

NEUROLOGICAL: Examination revealed the presence of slight tingling of upper limbs. There were also notable difficulties in moving the feet after any slight stagnation. There was, however, no evidence of headache, dizziness, or reports of fainting.

MUSCULOSKELETAL: Examination revealed slight stiffness in the lower extremities. There was however no joint, back, or muscle pain.

HEMATOLOGIC: Hematologic examination revealed no notable bruising or active bleeding. The patient was also not anemic.

LYMPHATICS: Lymphatic system examination revealed no swelling on the lymph nodes. The patient also has no history of splenectomy.

ENDOCRINOLOGIC: Endocrinologic exam revealed no notable polyuria or polydipsia. The patient, however, exhibited slight sweating of the palms and the neck region.

Diagnostic results: Requested diagnostics included head CT scans and blood tests. A Head CT scan was requested to eliminate physical injuries to the heart that may be contributing to the symptoms presentation of the patient (Chen et al., 2020). CT scan results revealed the absence of a physical head injury that may be worsening the patient’s symptoms. Blood tests were requested to rule out substance abuse that may also be contributory to symptomatic exacerbations in the patient. The blood test result was, however, positive of cigarette, alcohol, and cannabis. Drug use has been implicated in symptom exacerbation in psychotic patients (Nielsen et al., 2017). This may have been the reason for his symptoms worsening.

Assessment

Mental Status Examination: Mental assessment revealed that the patient appeared appropriately dressed and was wary of the time and occasion. The patient was well behaved and did not exhibit irregular behavior during the assessment. The patient admitted to having several episodes of suicidal ideation and had had an unsuccessful suicide attempt once.

Differential Diagnoses: This patient’s differentials include schizophrenia, bipolar disorders, and anxiety disorders. Schizophrenia is a complex psychiatric disorder that is characterized by impaired cognitive functions, hallucinations, delusions, and disorganization of speech and behavior. According to the DSM 5 manual on the diagnosis of psychiatric disorders, a positive diagnosis of schizophrenia is made when a patient presents with two or more symptoms of schizophrenia within one month of presentation to the clinic (McCutcheon et al., 2020). The symptoms identified in the patient above are consistent with those described in DSM 5. These include the presence of hallucinations, delusions, and disorganized speech, all having occurred within the last month. The patient, therefore, has a positive diagnosis of schizophrenia.

Bipolar disorder is a mood disorder that is characterized by alternating symptoms of mania and depression. The manic phase of bipolar disorder is characterized by grandiosity, restlessness or agitation, increased goal-directed activity, irritability, increased speech, reckless behavior, and racing thoughts. The depressive phase of bipolar is characterized by the classic symptoms of depressive disorders. According to DSM 5, a positive diagnosis of bipolar is made when three or more bipolar symptoms occur in an individual within one week of presenting to the hospital (Vieta et al., 2018). The patient above presented with increased speech and was restless. Collaborative history also revealed the occurrence of depressive-like symptoms in the patients. A combination of the patient’s presenting symptoms and collaborative history from the family indicated a positive diagnosis of bipolar in the patient.

Major depressive disorder is a psychiatric condition characterized by a constant feeling of guilt and sadness, lack of interest, lack of motivation, reduced concentration, alterations in psychomotor activities, and suicidal ideations or attempts. According to DSM 5, a positive diagnosis of major depressive disorder is made when five or more of these symptoms occur in an individual within two weeks of hospital presentation (Otte et al., 2016). Whereas some of these symptoms were apparent in the patient, they did not meet the criteria for a positive diagnosis of major depressive disorder. The patient’s symptoms that pointed towards this differential included reports of suicidal ideation, lack of motivation, and weight gain within the last two weeks. These were, however, not sufficient to qualify him for major depressive disorder.

Reflections: Schizophrenia remains the most common functional psychiatric condition in the US. This disorder is characterized by marked disruptions in thought processes. Schizophrenia is a chronic progressive disease that presents with several symptoms. A positive diagnosis of schizophrenia is made by a combination of clinical assessment of patient-specific symptoms and relevant diagnostics. Accurate diagnosis is therefore dependent on a comprehensive evaluation of the patient to identify symptom clusters that are consistent with the symptoms classification for schizophrenia as defined in the DSM manual.

I agree with my preceptor’s assessment and diagnostic impression of the patient. The findings and conclusions drawn by the preceptor were aligned with the available literature on psychiatric evaluation as well as with my class knowledge of psychiatric disorders. The case reinforced my class knowledge of mental disorders and also equipped me with the necessary skills utilizable in assessing patients with mental disorders. As a professional nurse, I will utilize my knowledge of predisposing factors to psychiatric disorders to educate the general public to enable them to understand the behavioral aspects that may predispose them to such conditions.

Handling psychiatric patients presents considerable difficulties in care provision processes. Understanding that these patients are human beings and that their incarcerations are attributable to their disease is, therefore, key to their management. Ethical provisions of doing no harm, justice, respect, and doing good that define nursing practice, therefore, apply to them. Caregivers should do all that is necessary to enhance the lives of psychiatric patients. Health promotional activities are critical in this regard. Health promotion should entail comprehensive public education on modifiable factors that predispose them to mental conditions. behaviors such as smoking increase the propensity to develop schizophrenia in patients with other predisposing factors such as genetic involvement (Nielsen et al., 2017). All these should be made known to the public.

References

Chen, Y., Pan, C., Chang, C., Chen, P., Chang, H., & Tai, M. et al. (2020). Physical Illnesses Before Diagnosed as Schizophrenia: A Nationwide Case-Control Study. Schizophrenia Bulletin, 46(4), 785-794. https://doi.org/10.1093/schbul/sbaa009

McCutcheon, R., Reis Marques, T., & Howes, O. (2020). Schizophrenia—An Overview. JAMA Psychiatry, 77(2), 201. https://doi.org/10.1001/jamapsychiatry.2019.3360

Nielsen, S., Toftdahl, N., Nordentoft, M., & Hjorthøj, C. (2017). Association between alcohol, cannabis, and other illicit substance abuse and risk of developing schizophrenia: a nationwide population-based register study. Psychological Medicine, 47(9), 1668-1677. https://doi.org/10.1017/s0033291717000162

Otte, C., Gold, S., Penninx, B., Pariante, C., Etkin, A., & Fava, M. et al. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1). https://doi.org/10.1038/nrdp.2016.65

Vieta, E., Berk, M., Schulze, T., Carvalho, A., Suppes, T., & Calabrese, J. et al. (2018). Bipolar disorders. Nature Reviews Disease Primers, 4(1). https://doi.org/10.1038/

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My patient was a 36-year-old male with schizophrenia and mood disorder.

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, which provides 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 and a PDF/image 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.