COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION
Order Instructions
Hello, below is the information of my patient for this assignment and the instructions for the assignment. This is a professional nurse practitioner program, so please use critical thinking with diagnoses and reflection. Please see the template for this assisgnment and exampler attached. Please use template for this assignment. Use APA 7 format for citation and references. Please let me know if you need more info.
Instructions:
For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.
Review this week’s Learning Resources and consider the insights they provide.
Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) 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.
Then, based on your evaluation of this patient, include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, 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.
Address the following:
Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
LEARNING RESOURCES
Required Readings
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Chapter 31, “Assessing Personality Disorders”
Chapter 32, “How to Educate Your Patient”
The patient and information:
S.G. 49 y/o female seen in clinic for initial psychiatric evaluation.
Pt needs grieving services. My past hunt me. I live alone, get housing thru housing services thru section 8. Have financial problem. No father, no mother. Was pregnant at 13 y/o and have 5 kids at 19 y/o. Family raise her kids after their father died while patient was 19years old. Owe state of VA over $250,000 in child support areas. Second daughter died at 30 yrs old from pancreatic CA. daughter was cremated and wasn’t given any ashes. Pt said if she works, all her money goes to child support. Sometimes I check out, I put my phone on do not disturb. Family will call police to do welfare check on her.
No drug, no alcohol,
Have had 3 heart attack, have stents, HTN, High Cholesterol
No allergies
Hopitalized for HA
No family hx of psyhe issue
Sexual abuse from cousin, mother was verbally abusive- said wish she left her at hospital
No relationship with father – who is alive, lives in Georgia
Highest education is 10th grade
Have 5 kids all girl, 2nd daughter pass away and in their 30s. All very successful
Felony – minor felony that cannot be expunge.
Pt was incarcerated for 45 days in Fairfax co. for child support.
Pt want to go back to school for GED
Patient said can’t sleep night. Sleeps during the day
Have one female friend who asked her to seek psyche help. Had boyfriend who gave her sexual transmitted disease trichomonas is on antibiotic. Pt does not use contraceptive.
Pt said she have low self esteem because of her weight and her past. She thinks if she go somewhere, everyone is watching her.
Pt said she talks to herself.
Weight 272 lbs, Ht = 5’ 5’
Have low motivation. Pt binge eat and then throw up. Pt feel bad about herself. Pt denies HI/SI, but wish she would get HA and die so all her bills can go away. Pt said her kids does not know she feels low and have so much issue. Pt reports hyperactive, very loud.
Pt crying throughout interview
PHQ- 9 Scale 24/27
Diagnosis: 1: GAD, 2:MDD, 3: Schizoid affective disorder, 4: PTSD
Pt crying throughout interview
Plan: Referral to PRP specialist, Psychotherapist, case manager
Before medication – need pregnancy test. Have PCP appt on 10/19, will need pregnancy test and lab work
Medication: Wellbutrin, Hydroxyzine – for anxiety and sleep. Abilify – for schizoid affective issue
Incorporate moderate exercise daily
Call office in 2-4 weeks if no call from therapist and referral services
Subjective: Pt is a 49-year-old AA female seen for psychiatric evaluation. Pt stated that “I do need grievance services and I can’t deal with a lot of life stressors going on with me”. Pt stated that she lives alone and she has been dealing with so many life traumas all her life. She noted that she is overwhelmed and confused and doesn’t know how to keep going. she stated that she had her first child at @13 and by 5th child age of 19 for the same man she noted that her partner died and she had to take care of her children before she lost their custody to family members. She noted that she owe the state of Virginia the sum of $250,000.00 in child support and the government has been taking almost everything she earns. she stated that she lost one of her daughters to pancreatic cancer and she can’t see her grandchildren. She noted that she feels like “I have a dark cloud over my head and every other person are in the sunshine” ” She reported that she has gained weight, can’t sleep, losing her hair, have had three heart attack, and 5 stents in her arteries. she stated that she feels like “checking out on life so all these problems will just go away”. she stated that doesn’t do drugs and doesn’t smoke. She noted that she can’t stay focused and doesn’t know where to start rebuilding her life. She reported that she had a felony charge some years ago for possession and has been incarcerated for 45 days for non-payment of child support. She stated that she was sexually abused by her cousin when growing up, and both parents were not in the picture and she doesn’t have any relationship with them. She reported that her grandmother has been helpful. she said she was homeless but currently suing housing services. she noted, “I feel overweight, can’t sleep on my bed, and I have poor self-esteem”. she ended by stating that she sometimes feels like “i don’t want to be in this life anymore
Objective: Mental Status Examination
General Appearance: Neat & clean., Poor Hygiene. Tired. Disheveled. Inappropriate. Other:
Eye contact: Normal. Avoidant. Intense. Other
Psychomotor Activity: Normal, retarded or rigidity/repetitive movements
Orientation: Person. Place. Time. Situation.
Attention: Intact. Distracted. Confused. Inattentive. Other:
BEHAVIOR: Cooperative. Resistant. Tired. Paranoid. Anxious. Guarded. Defensive. Agitated, Impulsive. Withdrawn. Stereotyped. Hyperactive. Other:
SPEECH: Normal. Tangential. Pressured. Slowed. Rambling. Mute. Soft. Loud. Other: ??.
MOOD: Euthymic. Euphoric. Dysthymic. Angry. Depressed. Irritable. Anxious. Hostile. Neutral. Elated. Apathetic
AFFECT: Appropriate.Manic. Blunted. Labile. Full. Constricted. Flat. Reactive. Restricted. Incongruent. Exaggerated.
THOUGHT PROCESS: Linear. Goal Directed. Illogical. Disorganized. Poverty of Thought.
THOUGHT CONTENT: Intact. Flight of Ideas. Tangential. Blocking. Circumstantial. Loose.
PERCEPTIONS: Good. Fair. Poor
INSIGHT:Good. Fair. Poor.Poor.
JUDGMENT: Good. Fair. Poor.
COGNITION: : Intact, Fair. Poor.
Language. WNL. Abnormal
MEMORY: None. Immediate. Recent. Remote.
C-SSRS (CURRENT)
1. WISH TO BE DEAD;
have you wished you were dead or wish you could go to sleep and not wake up? NO
if yes, describe:
2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS:
have you had any thoughts of killing yourself? NO
if yes, describe:
3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT
have you been thinking about how you might do this? No
if yes, describe:
4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN
have you had these thoughts and had some intentions of acting on them? No
if yes, describe:
5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT
have you start to work out or worked out the details of how to kill yourself? No
if yes, describe:
C-SSRS (LIFETIME)
1. WISH TO BE DEAD; No – Denies
have you wished you were dead or wish you could go to sleep and not wake up? Yes
if yes, describe: Pt noted that she “sometimes wishes it just happens”
2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS: In the past, not now. No
have you had any thoughts of killing yourself?
if yes, describe:
3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT
have you been thinking about how you might do this? NO
if yes, describe: Self mutilating. Cutting wrist
4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN.
have you had these thoughts and had some intentions of acting on them? NO
if yes, describe: Cutting wrist
5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT: NO
have you start to work out or worked out the details of how to kill yourself? NO
if yes, describe:
PROTECTIVE FACTORS: “Her Niece and her religion”
RISK ASSESSMENT: Low
SAFETY PLAN RECOMMENDATIONS: TO CALL 911 IF FEELING SUICIDAL
Psychosis: Y/N
Diagnosis Formulation:
Score on Administered Screening Tool: PHQ score 24/27, GAD: significant
Assessment: Pt is a 49-year-old AA female seen for initial psychiatric evaluation. Pt noted that she is overwhelmed by her life traumas and doesn’t know how to move on. Pt was emotional and crying while highlighting that she is having financial and relationship challenges. She reported that she owes the state of Virginia the sum of 250 thousand dollars for child support and almost all of her paycheck is taken by the State leaving her with as little as “80 dollars” to survive on. She reported childhood sexual abuse by her cousin and noted that both parents abandoned her when she was 8. She currently doesn’t have any relationship with them. She lives alone and doesn’t have anybody to talk to. She expressed despair stating “i don’t know what to do with my life and I sometimes feel like I don’t want to be in this life anymore”. Pt is overweight and lacks self-confidence and self-esteem. She noted that she could not sleep and felt depressed and down most of the time. Pt is sexually active and reported that she contracted an STD in her previous relationship and she is currently treating it. she has a history of 3 heart attacks and has five stents placed in her arteries.
The patient scored 24/27 on the PHQ-9 scale and scored significantly high on the GAD scale indicating.
Given the patient’s presentation and history, the patient is assessed for Depression and anxiety, schizoaffective disorder, and PTSD.
The patient will benefit from psychotherapy to help the patient develop positive coping skills to manage life stressors. Pt will also require the services of a case manager to help the patient access resources in the community for job placement. PRP will help the patient with the challenge of a backlog of child support owed to the State of Virginia. Pt will be prescribed Wellbutrin for depression, Hydroxyzine for anxiety, and also with sleep. Depakote for mood. Pt was encouraged to practice sleep hygiene and sleep on her bed. Pt also to eat healthy and engage in physical exercise. Pt will obtain a pregnancy test, thyroid test, and metabolic panel test as well to rule out other medical conditions that may mimic mental health disorder./
Diagnosis
(F33.2) Major depressive disorder, recurrent severe without psychotic features
(F41.1) Generalized anxiety disorder
(F43.12) Post-traumatic stress disorder, chronic
(F25.9) Schizoaffective disorder, unspecified
Medications :
Bupropion HCl (Wellbutrin SR) 150 MG Oral Tablet Extended Release 12 Hour
Divalproex Sodium (Depakote) 250 MG Oral Tablet Delayed Release
Hydroxyzine HCl (hydrOXYzine HCl) 25 MG Oral Tablet
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