Comprehensive Psychiatric Evaluation and Patient Case Presentation

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Week 7: Comprehensive Psychiatric Evaluation And Patient Case Presentation

Catherine Nwosu

Master of Science in Nursing, Walden University

NRNP 6635-24: Psychopathology and Diagnostic Reasoning

Dr. Tabitha Perrigo

October 17, 2021

Comprehensive Psychiatric Evaluation And Patient Case Presentation

Schizophrenia refers to a serious mental health disorder in which individuals have

problems interpreting reality in a normal way (McCutcheon et al., 2019). Schizophrenia

involves a mix of delusions, hallucinations, and extreme disordered thinking and behavior

that can impact the daily functioning of an individual. Individuals with Schizophrenia often

require lifelong treatment because the disorder impacts their ability to think, feel, and

behave clearly (McCutcheon et al., 2019). It is difficult to identify a specific cause of

Schizophrenia although it is believed to result from a combination of genetics, altered

brain chemistry and structure, and environmental causes (Fond et al., 2021).

Characteristics of Schizophrenia include thoughts or experiences that seem to be out of

touch with reality and reduced participation in daily activities. Treatment for Schizophrenia

often works by combining several strategies as psychotherapy, medications, and

coordinated specialty care services (Fond et al., 2021). Schizophrenia falls under

psychotic disorders and it affects less than 1% of individuals in the United States (Fond et

al., 2021).

Conducting a comprehensive evaluation during the assessment and diagnosis of

patients with Schizophrenia is important to pinpoint the exact factors that point to

Schizophrenia as the primary diagnosis. This paper is aimed at constructing a

comprehensive psychiatric evaluation that comprises of differential diagnosis and

reflection notes about a patient who is presenting with symptoms of Schizophrenia.

CC (chief complaint): " I have lots of issues at work and it is stressing me out.”

HPI: The patient is a 39-year-old female who presents to the clinic via telehealth with

consent obtained complaints of having lots of issues at work which stress her out. The

Tabitha Perrigo DNP PMHNP

Good clear chief complaint

patient explains that she is currently seeing a new psychiatrist because her previous

provider does not accept health insurance anymore. The patient explains that she has a

history of a past diagnosis of Schizophrenia in 2018 after having an episode. She

explains that the job she had during that time presented some issues that significantly

contributed to her symptoms. She admits to being admitted to a psychiatric hospital in

2018 where the diagnosis of Schizophrenia was made. The patient was initially

prescribed Zoloft 20MG together with injections of Aristada for 1.5 years. However, she

explains that she stopped taking the injections because she could not afford it. Recently,

the patient began taking Risperidone 2MG. Other current medications include

Risperidone 2 MG Oral Tablet, Fluoxetine HCl 20 MG Oral Capsule, and Benztropine

Mesylate 1 MG Oral Tablet. Her father has dementia and no other medical issue is

reported about other family members.

Past Psychiatric History:

 General Statement: The patient has a previous diagnosis of Schizophrenia that

was done in 2018.

 Caregivers (if applicable): Primary Care Provider

 Hospitalizations: the patient was hospitalized back in 2018 in a psychiatric facility.

 Medication trials: Risperidone 2 MG Oral Tablet, Fluoxetine HCl 20 MG Oral

Capsule, and Benztropine Mesylate 1 MG Oral Tablet.

Tabitha Perrigo DNP PMHNP

He provided her past history but no actual current symptoms that brought her in for today's visit the HPI as a history of present illness do you want to include the information you did but what are the current signs and symptoms that she's presenting with how often are they occurring how severe are they what makes it better what makes it worse.

 Psychotherapy or Previous Psychiatric Diagnosis: the patient has a previous

psychiatric diagnosis of schizophrenia that was done in 2018 during her

hospitalization.

Substance Current Use and History: explains that she does not smoke although she

admits to social drinking at least twice a year.

Family Psychiatric/Substance Use History: father has dementia although apart from

this, there is no other medical health issues reported regarding the other family members.

Psychosocial History: The patient had a normal birth and grew up with both parents.

She obtained her GE and has two siblings. She enjoys going to the movies, watching TV,

and shopping. The patient is a Christian and she explains that she has good appetite.

She admits to being straight or heterosexual and identifies as a female. The patient

explains to having a difficult time maintaining her job although she works for a temp

agency currently and it seems to be going well. The patient is not in a relationship and

denies any sexual activity. She lives alone and the nature of the relationship between her

and her siblings is not provided.

Medical History: Schizophrenia

 Current Medications: Risperidone 2 MG Oral Tablet, Fluoxetine HCl 20 MG Oral

Capsule, and Benztropine Mesylate 1 MG Oral Tablet.

 Allergies: has no known drug, food, or environmental allergies.

 Reproductive Hx: Heterosexual

Tabitha Perrigo DNP PMHNP

What about other substances such as Hallucinogenics methamphetamines caffeine cocaine those type of medication you need to be sure to document a clear substance use history

Tabitha Perrigo DNP PMHNP

Did she have any psychotherapy or therapist or was her only treatment medication?

ROS:

 GENERAL: Does not have weight loss, fever, chills, weakness, or fatigue.

 HEENT: Does not have visual loss, blurred vision, double vision, or yellow sclerae.

Does not have hearing loss, sneezing, congestion, runny nose, or sore throat.

 SKIN: Does not have visible rash or itching.

 CARDIOVASCULAR: does not have chest pain, chest discomfort, or chest

pressure. Does not have palpitations or edema.

 RESPIRATORY: does not have shortness of breath, cough, or sputum.

 GASTROINTESTINAL: Does not have vomiting, nausea, or diarrhea.

 GENITOURINARY: does not have burning sensation during urination; the color is

standard; has normal odor.

 NEUROLOGICAL: does not have headaches, dizziness, seizures, tremors, ataxia,

paralysis, numbness, or tingling in the extremities.

 MUSCULOSKELETAL: Does not have muscle pain, back pain, joint pain, or

stiffness.

 HEMATOLOGIC: Does not have anemia, bleeding, or bleeding.

 LYMPHATICS: Does not have enlarged nodes. Does not have history of

splenectomy.

 ENDOCRINOLOGIC: Does not have reports of sweating, cold, or heat intolerance.

Does not have polydipsia or polyurea.

Physical exam: VITAL SIGNS

Height: 5’9”

Weight; 154 lbs.

BP: 138/76

Temperature: 97.3F

Pulse: 88

Respiratory rate: 20

O2 Saturation: 98%

Pain: No complaint of pain verbalized during evaluation.

Diagnostic tests/results:

Patient Health Questionnaire screening was administered which is a diagnostic

instrument for assessing common mental disorders. It is specifically used in assessing

whether the symptoms presented are in correspondence to those of depression.

Blood tests or MRI could also be used by the provider to rule out any medical conditions.

Tabitha Perrigo DNP PMHNP

What specific blood test would you want to order why and what evidence supports it

Tabitha Perrigo DNP PMHNP

White scholarly sources support the use of the patient health questionnaire?

Assessment

Mental Status Examination:

The patient is a 39-year-old female who looks her stated age. She is oriented to

person, place, time and situation and her general appearance is neat and clean. The

patient has a normal eye contact and psychomotor activity involves repetitive movements.

Her attention is intact and she is cooperative with the examiner. The patient has a normal

speech with a euthymic mood and appropriate affect to her mood. Her thought process is

goal-directed and her thought content is intact. The patient has good perception and

insight with fair judgment and cognition. Her language is appropriate and she has good

immediate, recent, and remote memory. The patient has no suicidal or homicidal

ideations.

Differential Diagnoses:

Schizophrenia

The most likely primary diagnosis for this patient is Schizophrenia. This is because she

has a history of previous diagnosis of Schizophrenia in 2018. It is likely that the patient is

undergoing a relapse of Schizophrenia because according to research, symptoms of

Schizophrenia can get better when it is under control but the individual may undergo a

relapse and the symptoms will come back if it is no longer controlled (Lieberman & First,

2018). This is true for this patient because after being diagnosed with Schizophrenia , she

was put on Zoloft 20MG and was getting injections of Aristada for 1.5 years but later on

stopped taking the injections due to her inability to afford it. The failure to take medicine

Tabitha Perrigo DNP PMHNP

This is a patient who carries a diagnosis of schizophrenia but you do not assess or if specifically address if hallucinations are delusional thought processes are present this is a requirement of assessing a patient with a history of schizophrenia but a assessment should always include if hallucinations or psychotic symptoms are present.

as instructed is the most common cause of any relapses in Schizophrenia and is likely to

be the case of the patient (Fond et al., 2021).

Schizoaffective Disorder

This is also a possible diagnosis for the patient because the symptoms for this condition

often resemble those of Schizophrenia with the addition of mood symptoms (Boerrigter et

al., 2017). However, this diagnosis can be ruled out because the symptoms of the patient

are better explained by Schizophrenia disorder especially due to the fact that the patient

has a history of the disorder.

Bipolar Disorder

This is a possible diagnosis for this patient because the patient’s symptoms of having

issues at work that stress her out resemble those of bipolar disorder. This is because

individuals with bipolar disorder are more prone to stress and they have a hard time

recovering from, and adjusting to stressors (Grande et al., 2016). Also, the symptoms for

this disorder are similar to those of Schizophrenia and Schizoaffective disorder making it

a possible diagnosis (Grande et al., 2016). However, the diagnosis is ruled out because

the patient does not report periods of elevated moods and mania or depression which is

characteristic of this condition (Fond et al., 2021). Also, the patient’s a previous history of

Schizophrenia explains her symptoms better.

Plan of Care

The plan includes strategies of continuing to stabilize the symptoms of

Schizophrenia in the next 90 days. It also involves encouraging the patient to complete a

physical and get yearly labs and to adopt positive coping skills such as walking,

Tabitha Perrigo DNP PMHNP

What signs and symptoms of schizophrenia was she presenting with at the time of the evaluation

journaling, and deep breathing exercises (Fond et al., 2021). The plan of care also

involves encouraging the patient to call 911 in the event of suicidal or homicidal ideations.

Patient is to follow up in two weeks.

Reflections:

In order to successfully controls Schizophrenia, it is important to combine several

approaches such as the use of psychotherapy, medication, and behavioral therapy. It is

important to understand the relapses in Schizophrenia in detail and how they occur. An

element that I would do differently would be obtaining more information about the

patient’s previous psychiatric hospitalization in 2018. One ethical consideration that I

would apply in the case of the patient is establishing a background of her financial

situation to understand reasons that made her unable to afford taking the injections and

her current financial position regarding her ability to obtain prescribed medication.

Conclusion

Schizophrenia is well controlled when a patient is adhering to the treatment plan

including taking the medication because this prevents relapses. It is important to advise

the patient on the possible side effects of the medication and how to manage them. It is

also significant to assess the prescribed medications for the patient and the possible

contraindications that may occur.

References

Boerrigter, D., Weickert, T. W., Lenroot, R., O’Donnell, M., Galletly, C., Liu, D., ... &

Weickert, C. S. (2017). Using blood cytokine measures to define high inflammatory

biotype of schizophrenia and schizoaffective disorder. Journal of

neuroinflammation, 14(1), 1-15.

Fond, G., Pauly, V., Leone, M., Llorca, P. M., Orleans, V., Loundou, A., ... & Boyer, L.

(2021). Disparities in intensive care unit admission and mortality among patients

with schizophrenia and COVID-19: a national cohort study. Schizophrenia

bulletin, 47(3), 624-634.

Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The

Lancet, 387(10027), 1561-1572.

Lieberman, J. A., & First, M. B. (2018). Psychotic disorders. New England Journal of

Medicine, 379(3), 270-280.

McCutcheon, R. A., Abi-Dargham, A., & Howes, O. D. (2019). Schizophrenia, dopamine

and the striatum: from biology to symptoms. Trends in neurosciences, 42(3), 205-

220.