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College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): “ I feel like jumping into traffic to end it all. I do not have a place to stay”.

HPI: Patient (B.W.) is a 50 years old Caucasian male who presents with a complaint of a psychiatric problem and is for a screening exam. The patient came to the hospital voluntarily for depression and suicidal ideation with a plan to jump into traffic to end it all. The patient reported feeling hopeless, helpless, and worthless since his recent divorce from his wife. The patient has been feeling depressed for the past four weeks, which been worsened over the past two weeks. The patient reported having an altercation with the group homeowner, causing him to leave and become homeless. The patient said having been more depressed since then, with passive death wishes as an outcry to seek help. The patient reports drinking alcohol up to 7 beers a day in episodic binges and cannabis use when he can but denies tobacco or other drugs. The patient also said his medications don’t seem to be working at this time. The patient states, “ I took Sertraline, but I got more depressed.”The patient reports mood swings and negative thought processes and is easily agitated.

Past Psychiatric History:

· General Statement: The patient entered his first psychiatric treatment last year while going through his divorce in June and was diagnosed with depression disorder.

· Caregivers (if applicable): N/A

· Hospitalizations: No prior hospitalizations; however, the patient has been seeing a psychiatrist for treatment.

· Medication trials: Patient report taking Sertraline 50mg a day

· Psychotherapy or Previous Psychiatric Diagnosis: The patient was previously diagnosed with depression disorder. The patient was once sent to a rehab program but did not stay. The patient has a prior psych history of mood, anxiety, intellectual disability, and polysubstance abuse (EtOH, cannabis, and cocaine).

Substance Current Use and History:

The patient reports daily usage of alcohol; the last drink was the day before coming to the hospital. The patient reports drinking alcohol up to 7 beers a day in episodic binges and cannabis use when he can but denies tobacco, denies heroin, denies cocaine, denies benzodiazepine, and denies other drugs. Denies withdrawals, including seizures and DTs. The patient does report alcohol cravings at the time .

Family Psychiatric/Substance Use History:

The patient reports that his father is an alcoholic, and his mother suffers from depression. His mother committed suicide when he was ten years old. Denies family substance abuse and denies family medical problems.

Psychosocial History: This patient was born in Miami, Florida, and was living with his gramma and his father after the death of his mother when he was ten years old. Currently, the patient resides in Individual Living Facility (ILF) but got discharged after an altercation. The patient never had any children, and now the patient is currently going through a divorce. The patient does not have any brothers or sisters. The patient said he is still traumatized today by the death of his mother. He found his mother dead on the floor when he was ten, and he tried to revive her but couldn’t, so he still blamed himself for her death. The patient reports having PTSD and a learning disability. The death of his mother still traumatized him, and he couldn’t stay focused in school and only went up to 7th grade because he was told he would never receive a high school diploma, so he dropped out of school. The patient is currently unemployed. The patient said he never had a good job because he did not have the education to get a good job. He is collecting disability payment for his intellectual learning disability. The patient has no arrest history.

Medical History: Patient denies any medical history, illness, and hx of seizures and head injuries.

· Current Medications: Sertraline 50 mg PO BID for depression

· Allergies: No Known Allergies

· Reproductive Hx: Male, no children

ROS:

· GENERAL: Denies fever, chills, dizziness, weakness

· HEENT: Denies redness, Denies discharge, Denies visual loss, Denies blurred vision, Denies vision change, Denies sore throat, Denies nosebleed, Denies rhinorrhea, Denies throat swelling, Denies hearing loss

· SKIN: Denies rash, Denies swelling, Denies lacerations, Denies abrasions

· CARDIOVASCULAR: Denies chest pain, Denies rapid heartbeat, Denies lower extremities swelling, Denies palpitations, Denies orthopnea.

· RESPIRATORY: Denies SOB, Denies productive cough, Denies hemoptysis

· GASTROINTESTINAL: Denies nausea, Denies vomiting, Denies diarrhea, Denies constipation, Denies bloating, Denies melena

· GENITOURINARY: Denies Dysuria, Denies frequency, Denies flank pain, Denies hematuria

· NEUROLOGICAL: Denies headaches, Denies numbness, Denies change LOC, Denies weakness, Denies paresthesia, Denies change in speech

· MUSCULOSKELETAL: Denies myalgia, Denies neck/back pain, Denies arthralgia, Denies redness

· HEMATOLOGIC: No bruising, No petechiae, No bleeding noted

· LYMPHATICS: Denies any swollen nodes

· ENDOCRINOLOGIC: Denies polyuria, Denies polydipsia, Denies polyphagia

Physical exam: No physical exam is required at this time

Diagnostic results: TSH, CPM, BMP, CBC, and labs would be performed to rule out any psychiatric symptoms related to medical conditions. The Mood questionnaire would be provided to the patient to assess for bipolar disorder.

Assessment

Mental Status Examination: The patient is a 50 years old Caucasian male who looks his stated age. His behavior is calm and cooperative with the examiner. The patient orientation intact sensorium is awake, to person, place, day, date, month, and year. The patient is appropriately dressed for the weather. His appearance is eccentric; however, he is malodorous and disheveled due to homelessness. The patient is calm, stable, and with a low energy level. He has good eye contact during the assessment, but most of the time patient seems to be gazing away. His speech is comprehensible. His mood is Euthymic. His affect content is congruent. His thought process is goal-directed and logical. The patient appears to be depressed and sad. The patient currently denies suicidal and homicidal ideation at the present time. Denies pain and discomfort at the present time. Patient insight is fair, and his judgment is Fair.

Differential Diagnoses:

Reflections:

References

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