Sample NSG 535 PSYCHIATRIC EVALUATION
Identifying Information
AL is a 40-year-old unemployed, married Caucasian male. The patient states his “drug of choice is meth and heroin/fentanyl.” The patient was the primary source of information. The patient was able to provide an account of her life’s events in chronological order to the best of his ability for what he was able to recall.
SUBJECTIVE
CC: “My anxiety is bad, and I’m not sleeping.”
HPI:
The patient presents from home for inpatient rehab. He has been abusing meth and heroin/fentanyl daily for two years. As a result, he struggles with chronic excessive anxiety. AL graduated from high school, but he has always had poor concentration and difficulty focusing. He also has increased restlessness. He has a hard time staying asleep and then feels tired the next day. He has been sober for three months, about a year ago.
He started hearing voices around the age of 13-14yrs. Shortly after, around the age of 14yo is when he began drinking alcohol and using crack cocaine. He said the crack and alcohol helped to “quiet the voices.” He never told anyone about the voices because he feared getting locked up. The voices continued during periods of depressed mood and without being in a depressed mood. He has also always been exceptionally disorganized; he thought he was just an unorganized person. His auditory hallucinations continue even during periods of sobriety. The voices were condescending to him, calling him” useless and worthless.” They would tell him to “kill himself because he didn’t deserve to live.” AL would also get messages from his tv that were meant just for him. The voice from his tv would tell him about “other bad people,” and the voice would tell him to “kill them, they deserve it” because they are evil.
AL has had a lot of traumas in his life. He has a history of physical, emotional, and sexual abuse, contributing to his anxiety and PTSD. He has witnessed and is a victim of physical abuse. He has a history of being sexually abused. He gets nightmares every night and flashbacks approximately 4-5 times a week. He startles easily, is hypervigilant, and has difficulties trusting others. He has struggled with concentration, irritability, and issues staying asleep all night, even during periods of sobriety.
Current medications and response:
1) Methadone 15mg- Give 1.5 tabs PO daily- effective
Past Psychiatric History:
The patient was diagnosed with Schizoaffective disorder, Anxiety, and Depression. The patient could not recall the psychiatrist who diagnosed him with Schizoaffective disorder. He does not have any substantial time of sobriety under his belt. This admission is his first time in a dual rehab facility. He had six psychiatric hospitalizations, the last being when he was 18yo after he overdosed. His previous suicide attempt was five months ago when he attempted to overdose on Fentanyl and received Narcan 3 times. He has a history of cutting and burning himself, which he last did at the age of 14 yo. He has not followed up with a Psychiatrist, counselor, or PCP in the past few years.
Prior Psychiatric Medications:
Ritalin- (hx of abusing them)
Seroquel- (side effect-weight gain)
Wellbutrin- (side effect-urinary frequency)
Zyprexa- (does not recall response)
Abilify- (side effect-none; response-ineffective)
Haldol- (side effects-muscle spasms)
Substance Abuse History/Addictive Behavioral Patterns:
The patient started doing drugs at the age of 14yo. He would drink alcohol 2-3 times a week until he was 33 years old. At 14yo, he also started smoking 0.5 gram of crack once a month for two years. He started using meth at the age of 33yo. He used 1 gram of meth daily IV for the past two years and last used on 3/15/22. He started using heroin/fentanyl at the age of 33 yo. He used two bags of heroin/fentanyl daily IV for the past two years and last used on 3/15/22. He handles his stress by self-medicating with drugs. He smokes 1.5 ppd of cigarettes and is not interested in quitting. He declined the tobacco cessation packet upon admission.
Medical History:
Asthma, HOH, denies any history of seizures
Prior Surgeries: hernia repair x 10 years ago
Allergies: NKDA
Review of Systems:
HEENT: No concerns
Respiratory: No concerns
Cardiovascular: No concerns
GI: No concerns
Neurological: No concerns
Endocrine: No concerns
Family Psychiatric History:
Maternal Grandfather sexual offender
Siblings and uncles have depression and anxiety
Mother and father- depression and anxiety
Sister- attempted suicide
Family Hx of substance abuse-paternal uncle and brothers
Psychosocial:
AL is from Olean, New York. He is the youngest and has an older sister. He graduated from high school. He identifies as a male, and his sexual orientation is heterosexual. He is unemployed. He lives alone. He has five children, but he does not have much interaction with them. He is married but separated from his wife. He does not have an extensive support system, only his mother. He has a pending petty larceny charge and is on probation. He is also a registered sex offender.
OBJECTIVE
Mental Status Exam:
AL is well-groomed; he has dark blond hair cut short near the scalp. He has dressed appropriately with multiple layers on for the cool weather. He is tall with a solid frame. He was wearing sweat pants and a sweatshirt that were slightly bagging but appeared clean with no stains, and he had no body odor. His face is symmetrical in appearance, but the lower half of his face is covered by his mask. He is alert and oriented to person, place, time, and situation. He is cooperative and would respond and answer all the questions asked. His speech is at an average rate, rhythm, and volume. However, his latency response is average in quality, and his speech’s general quality is average.
His affect is stable and is appropriate during our conversation. The patient’s range of affect is constricted, and his affect is flat The patient’s thought process is coherent. AL denies any thoughts of suicidal or homicidal ideation at this time. He denies having any visual hallucinations but is having auditory hallucinations and paranoia. AL’s recent and remote memory were not intact, as evident by scoring 1/3 objects after 5 minutes for recent memory and 2/2 past presidents for remote memory. Abstract and concrete thinking ability intact as evidenced by interpreting common proverbs and naming similarities between two objects.
ASSESSMENT
Diagnostic Impression with Formulation:
Current Diagnoses:
· F11.20- Opioid Use Disorder, Severe
· F25.1- Schizoaffective Disorder- Depressive Type
· F43.10- Post Traumatic Stress Disorder
· F41.1- Generalized Anxiety Disorder
Differential:
Differentials include delirium, major cognitive disorder, substance/medication-induced psychotic disorder, bipolar disorder, major depressive disorder with psychotic features, brief psychotic disorder, delusional disorder, or paranoid personality disorder (Association, 2013, p. 109).
AL meets DSM-V criteria for Schizoaffective Depressed type since he had an uninterrupted period where he had a major depressive mood and auditory hallucinations and was exceptionally disorganized (Association, 2013, p. 99 & 105). In addition, he has had auditory hallucinations for 2+weeks without being in a depressed mood episode and was also sober during the period.
AL is a 40yo man who has been using for the past two years and is non-compliant with his medications. He self-medicates with drugs to feel better and help quiet the voices. He has a genetic predisposition to substance abuse and has multiple family members with anxiety and depression. He experienced physical, emotional, and sexual trauma throughout his life and has coped the best way by self-medicating to numb the pain. His drug use has caused him legal problems. He is still on probation and is a registered sex offender. AL talks to his mother and thinks about his kids as his coping skill. He plans to go to a halfway house after rehab to help adhere to an excellent structured routine.
PLAN
Continue with the following medications as directed.
1) Methadone 15 mg- 1 ½ tabs daily
a. Finish methadone taper for two more days as directed.
2) Start Geodon 20 mg 1 tab PO BID
a. Antipsychotic medications are the preferred treatment for schizoaffective disorders. AL was previously on Seroquel, Abilify, Zyprexa, and Haldol and either did not tolerate them or had unwanted side effects. Therefore, we choose another second-generation medication Geodon, “they are generally preferred because they pose a lower risk of serious side effects than do first-generation antipsychotics” (“Schizophrenia,” 2021, second-generation antipsychotics section).
3) Start Minipress 1 mg- 1 tab PO BID
a. In a study by Hendrickson et al. (2021), “twice daily prazosin substantially reduced not only nightmares and sleep disruption, but the majority of hyperarousal symptoms, with some evidence of efficacy for avoidance symptoms” (conclusion section).
4) Continue Norvasc 2.5mg- 1 tab PO QD
5) Ventolin HFA 90 mcg- 2 puffs via inhalation every 4 hours PRN SOB d/t asthma
6) AL needs to establish care with a PCP for preventative care and routine care exams.
7) Counseling staff will assist AL in finding a local Psychiatrist near his home.
a. When it comes to diagnosing and treating Schizoaffective disorder, patients want to follow up with a Psychiatrist or Mental Health Nurse Practitioner. This is because they are specially trained in diagnosing and treating mental health conditions. Unfortunately, we have been behind in mental health, and since COVID-19 the need for mental health services has only worsened because of the way we currently overwork our mental health providers. In a study by Howard et al. (2019), “psychiatrists were also prone to compassion fatigue, pessimism and the adoption of negative coping strategies, such as excessive worrying, denial and overworking (psychological illness section).
8) I will get AL a referral for a case manager to be involved in his care.
a. Schizoaffective disorder is associated with social and occupational dysfunction (Association, 2013, p. 109). He will need help with obtaining a job, or if he is unable to keep a job, he might qualify for disability and will require assistance filling out the proper paperwork.
9) Provide support to AL and his support system. For example, sharing information with him and his mother and giving them information about local support groups to help prevent burnout for AL’s mother.
a. “Family members must also be encouraged to remain part of the support system, and strategies need to be used to the family involved” (Dziegielewski, 2010, p. 275).
Dziegielewski, S. F. (2010). Dsm-iv-tr in action (2nd ed.). Wiley. Howard, R., Kirkley, C., & Baylis, N. (2019). Personal resilience in psychiatrists: Systematic review. BJPsych Bulletin, 43(5), 209–215. https://doi.org/10.1192/bjb.2019.12
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