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Evaluation

Monica Castelao

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

January 24, 2022

Subjective:

CC (chief complaint): Chronic pain complications.

HPI: Katrina has been experiencing headaches and fatigue for over three months.

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Past Psychiatric History:

 General Statement: Katrina Bykov is a 41-years-old female. She has come for treatment

after experiencing chronic pain that makes it difficult for her to effectively engage in her

normal chores. She is currently under no medication.

 Caregivers (if applicable): Katrina lives with her parents.

 Hospitalizations: There is no history of previous inpatient admission, detoxification, or

rehabilitation for drug and substance use disorders.

 Medication trials: There are no medication prescriptions for Katrina regarding chronic

pain. She has been taking over-the-counter pain relief medications including

acetaminophen and ibuprofen. The pain relief medication has not been effective.

 Psychotherapy or Previous Psychiatric Diagnosis: Katrina has not undergone psychiatric

diagnoses in the past.

Substance Current Use and History: Katrina denies drinking and substance abuse.

Family Psychiatric/Substance Use History: The client's parents and siblings do not have a

history of alcohol abuse or drug use.

Psychosocial History: Katrina, who is 41 years old, was born in born in Russia but the family

moved to Washington when she was 12 years old. Both of her parents are still alive, and she has

two brothers and two sisters. Katrina has no children and has regular menses. She lives with her

parents and four siblings. She dropped out of school in 11 grade although she seems intelligent.

Currently, she is working part-time as a cashier at Aldi Grocery Store. Katrina has not had any

legal issues, violent partners, or traumatic experiences.

Medical History:

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 Current Medications: Katrina is currently under no medication. She had completed the

acetaminophen dosage a week ago that took for five days three times daily.

 Allergies: Katrina has no allergies to foods or environmental conditions.

 Reproductive Hx: The client has not had children. She has not had abortions or

pregnancies. Her menstrual cycle is regular. The client has not mentioned any sexual

concerns.

ROS:

 GENERAL: Katrina weighs 117 pounds or 53.1 kg. She is 5 feet 8 inches tall.

 HEENT: No visual impairments but she experiences blurred and double vision sometimes.

She has yellow sclerae. She hears well. Her throat is sore, and she experiences congestion.

 SKIN: She does not have rashes, but seems dry.

 CARDIOVASCULAR: Pulse rate-74; heart pressure 100/70

 RESPIRATORY: Shortness of breath and coughs.

 GASTROINTESTINAL: No vomiting, anorexia, or diarrhea.

 GENITOURINARY: Urine has an odor.

 NEUROLOGICAL: Feels dizzy, have a tingling sensation in the fingers and toes. Has

normal bowel control.

 MUSCULOSKELETAL: Experiences pain in the muscles, and stiff muscles.

 HEMATOLOGIC: No bleeding, no anemia.

 LYMPHATICS: Has not had a splenectomy. Normal lymph nodes.

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 ENDOCRINOLOGIC: No colds, heat intolerance, or sweating.

Objective:

Physical exam: The client looks tired. The face looks older than her age. Her cheekbones are

protruded. She has a straight gait, she has a slender body.

Diagnostic results: EtG-l 100ng/ml; X-ray images of the lungs shows signs of emphysema on

both lungs. Forced expiratory volume (FEV) and forced vital capacity (FVC) of less than 70%. An

electrocardiogram test indicates ventricular arrhythmia. Vitamin D blood test shows 15ng/ml of

blood. 75ng/ml of tetracannabinol was detected in the urine.

Assessment:

Mental Status Examination:

Katrina 41, is a Caucasian American woman who looks older than her age. She cooperates

well regarding responses to the questions asked. She appears neat and appropriately dressed. There

are no signs of abnormal motor events although her fingers appear shaky. She speaks in a normal

tone and volume and seems to be emotionally stable. She denies having had suicidal ideation and

any traumatic or violent experiences in the past. Katrina has never experienced hallucinations or

auditory and other cognitive impairments. There are no signs of delusional thinking and seems to

be alert. She has no problem concentrating.

Differential Diagnoses:

Alcohol and Substance Use Disorders

Katrina is suffering from chronic alcohol and substance use disorder. She is not suffering

from any diseases according to the laboratory report. Her blood pressure of 120/80 is elevated,

which indicates a problem with the cardiovascular and respiratory system associated with alcohol

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and substance abuse (Turner et al., 2018). Furthermore, her urine had an alcoholic odor, and her

eyes have yellow sclera. The x-ray results show signs of emphysema on both lungs, which indicate

that she has been smoking for a lengthy period (Turner et al., 2018). Alcohol and cannabis

addiction is associated with chronic headaches especially when users abruptly stop drinking and

smoking (Turner et al., 2018). Therefore, Katrina’s body needs to be detoxified of alcohol and

other drugs for her to recover from good health.

Major Depressive Disorder

Katrina can be suffering from major depressive disorder (MDD) due to historical and

current issues. For instance, although she has not stated it, Katrina's history appears not to have

been smooth. As an immigrant, she might have experienced inequality issues before being

accepted as an American citizen. Additionally, she dropped out of 11th grade, which implies that

the culture that influenced her to drop out of school can also have the caliber to cause depression. It

appears that she might not have been on good terms with her family after quitting school, which

according to psychodynamic theory can have serious repercussions in later life (Stavrou, 2018).

The signs of depression observed in her include chronic headache, moodiness, and tiredness.

Alcohol and smoking are known to cause depression (Stavrou, 2018). Therefore, Katrina's

depression seems to have been caused by stagnation regarding little success in life, and alcohol and

drug abuse issues as evidenced by her laboratory examination.

Generalized Anxiety Disorders

Katrina can also be suffering from a generalized anxiety disorder. The symptoms that point

to the disorder include chronic headache, tiredness, irritability, muscle fatigue, and tension

(Kendler et al., 2018). From the psychoanalytical perspective, the unfriendly childhood and

adolescence experiences that Katrina went through seem to have caused the anxiety (Stavrou,

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2018). Additionally, the current life that she lives in appears not to be as quality as that of her

siblings, which is a factor that is enough to cause worries given that she is working in a local

grocery store. Katrina might have resorted to alcohol and drugs to escape from her problems,

which has caused counterproductive effects on her health.

Reflections:

Katrina seems to be suffering from alcohol and substance use disorder. Going by her

history, she appears to have started abusing marijuana and alcohol in school. Her quitting school in

the 11th grade was likely influenced by her alcohol and drug abuse. Alcohol and drug-related

issues are the greatest cause of school dropouts among adolescents (Stavrou, 2018). There is no

history of drug abuse in the family. However, Katrina seems to have been influenced into drug and

alcohol abuse by her peers and the culture in the environment that she lives in. The most likely

reasons that point to drug and substance use disorder include traces of alcohol in the urine,

emphysema in both lungs, and yellow sclerae (Stavrou, 2018). Additionally, 75ng/ml of

tetracannabinol was detected in the urine, which indicates that she smokes bhang (Stavrou, 2018).

Chronic headache is associated with a long period of marijuana and alcohol abuse especially when

users withdraw.

Depression is also a likely diagnosis. The reason for its inclusion includes chronic

headache, disinterest in normal activities, and high elevated blood rate and pressure. However,

there are no serious challenges that Katrina has gone through in her life going by the information

she has presented. Therefore, the depression is likely to have been induced by alcohol and drug

abuse. Similarly, anxiety is a likely diagnosis because of chronic headaches. However, her appetite

and sleeping patterns are normal, which makes depression and anxiety less likely than drug and

substance abuse. Now that Katrina seems to have alcohol and drug issues, there are legal and

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ethical implications associated with her treatment. In that regard, it would be crucial to keep her

alcohol and marijuana abuse problems secret as much as marijuana is illegal for the welfare of the

client. Involving law officers would impact her confidence and trust in her healthcare provider, and

is likely to increase depression and anxiety.

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References

Kendler, K. S., Aggen, S. H., Flint, J., Borsboom, D., & Fried, E. I. (2018). The centrality of

DSM and non-DSM depressive symptoms in Han Chinese women with major depression.

Journal of affective disorders, 227, 739-744.

Stavrou, P. D. (2018). Psychoanalytic Psychotherapy as a Treatment for Depression in

Adolescents: A Case Study. Global Journal of Social Sciences Studies, 4(2), 91-101.

Turner, S., Mota, N., Bolton, J., & Sareen, J. (2018). Self‐medication with alcohol o rdrugs for

mood and anxiety disorders: A narrative review of the epidemiological literature.

Depression and anxiety, 35(9), 851-860.