Psychopathology

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Comprehensive Psychiatric Evaluation

Tina Cherry

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Dr. Clark

April 30, 2022

Subjective:

CC (chief complain): Substance abuse disorder

HPI: The patient is a 26-year-old white female who has to the facility complaining of difficulties in sleeping. The patient is an alert and oriented person; that is, she is able to recognize her name, where she is, and a particular point in time. The patient has also lost a significant amount of weight within one week. The patient reports being diagnosed with Bipolar disorder previously, and she has been placed on medication which she complains has led her to have too much sleep at night. She has lost a significant amount of weight. The patient is generally a happy patient, as she rates her happiness at 8/10.

Past Psychiatric History:

· General Statement: “I needed help because I could not sleep.”

· Caregivers (if applicable): No information regarding caregivers is provided

· Hospitalizations: The patient has previously been hospitalized in a psychiatric facility because she was not able to sleep.

· Medication trials: During her admission to the psychiatric facility, the patient was placed on Gabapentin which was administered in dosages of 600mg in the morning and noontime and 1200 mg at night. She has been prescribed 5mg of Abilify at night. The patient also reports trying Lithium during her inpatient admission.

· Psychotherapy or Previous Psychiatric Diagnosis: The patient has been previously diagnosed with Bipolar 1 Disorder and mild depression.

Substance Current Use and History: No history of drug or alcohol abuse

Family Psychiatric/Substance Use History: No history of substance use or psychiatric condition of the patient’s family is provided

Psychosocial History: The patient has previously had episodes of mild depression and bipolar disorder. She was placed on medication to address her sleep problem. Medications administered in the past include Gabapentin 600mg one tab daily and 1.5 tab nightly. She was also placed on Aripiprazole 5 mg tab nightly. Her past medication examination reveals mild depression severity and mild anxiety, which is evident by a GAD-7 score of seven. According to Johnson et al.(2019), a GAD-7 score of 5-9 indicates that a patient has mild anxiety.

Medical History:

· Current Medications: The patient is currently being treated for Bipolar disorder with Gabapentin tabs administered in 600 mg tab daily, 600mg, 1.5mg tab nightly, and Aripiprazole 5 mg tab nightly

· Allergies: The patient is allergic to Lithium

Reproductive Hx: No has no history of reproductive health complications.

ROS:

· GENERAL: The patient has no addiction issues

· HEENT: No swelling on the patient's head, and audio and visual acuity intact. The patient's EOM is intact

· There is no sinus infection

· Mouth: There are no muscossal lesions

· Teeth; No significant resorption

· Pharynx: Mucosa non-inflamed

· Neck: thyroid non-enlarged

· SKIN: No rashes on the skin. The skin is adequately moist

· CARDIOVASCULAR: Pre-Hypertension, Normal heart rate, No chest pain.

· RESPIRATORY: No cough, clear to auscultation

· GASTROINTESTINAL: No abdominal pain or vomiting episodes

· GENITOURINARY: Negative dysuria

· NEUROLOGICAL: The patient is alert, and she answers questions accordingly.

· No facial asymmetry

· MUSCULOSKELETAL: The patient has adequate muscle tone.

· HEMATOLOGIC: The patient does not have anemia

· LYMPHATICS: No swollen lymph nodes present

· ENDOCRINOLOGIC: No endocrinal conditions noted

Objective:

Physical exam: : BP; 122/75. HR; 88 bpm. Ht/Lt; 5’11”. Wt; 153 lbs 9 oz. BMI; 21.42. Pain; 0/10

Diagnostic results: Blood and urine tests returned unremarkable results.

Assessment

Mental Status Examination :

The patient is well-behaved. She is fairly groomed, and her hygiene is excellent. However, the patient feels restless throughout the interview process. Her speech is hyperverbal, stuttering initially; however, it improves as the conversation progresses. The patient has been previously hospitalized for bipolar disorder and shows no signs of highs and lows. The patient does not have suicidal or homicidal ideations; neither does she experience hallucinations but has difficulties finding sleeping patterns. PHQ-9 total score; 4. GAD-7 total score; 7

Differential Diagnoses:

Depression

Depression is a psychiatric illness that causes persistent feelings of sadness and loss of interest. Depression is classified into two categories; major depressive disorder and minor depression. Symptoms of minor depression include; anger, lack of interest or motivation, appetite changes, insomnia, weight changes, substance abuse, and pains with no particular cause (Tolentino & Schmidt, 2018). Symptoms reported by the patient include insomnia, weight loss, episodes of mania, and hypomania (Tolentino & Schmidt, 2018). Based on DSM 5 criteria for diagnosing minor depression, a patient must show at least the following symptoms; weight change, recurrent suicidal thoughts, insomnia, and hypersomnia every day, or at least one symptom must include anhedonia or dysphoria (Tolentino & Schmidt, 2018). Therefore, we can rule out the patient has mild depression.

Schizophrenia 

Schizophrenia is a mental illness in which patients interpret reality strangely. It might result in a combination of delusions, hallucinations, or extremely disorderly thinking or behavior s that may damage daily functioning (Carpenter, 2021). The most common symptoms of Schizophrenia based on DSM 5 criteria are; delusion, disorganized speech, hallucination, disorderly behaviors, and negative symptoms. In order to be diagnosed with Schizophrenia, at least two or more of the above symptoms must be present (Carpenter, 2021). The patient does not have delusions, disorganized speech, or hallucinations. The patient reports a lack of sleep and episodes of highs and lows. As such, she does not meet the DSM5 criteria for Schizophrenia.

Bipolar disorder

Bipolar disorder is a psychological illness that causes excessive mood swing, which includes episodes of high, lows, and depression. Studies show nearly half of people diagnosed with bipolar disorders will have a prevalence of mania and hypomania episodes—patients with Bipolar type 1 experience manic episodes and depressive disorders. On the hand, patients with bipolar type 2 will experience at least one episode of hypomania. Mania is the main DSM criterion for bipolar type 1, while hypomania is the differential diagnostic criteria of bipolar type 2. According to Kessing et al. (2021), manic patients engage in very risky activities such as substance abuse. They also experience sleep disturbances and restlessness. The patient experiences highs and lows and sleep disturbances and also exhibits some signs of minor depression. The symptoms of the patients meet the DSM criteria for diagnosis of bipolar type 1. Hence, we can rule that the patient has bipolar type 1 disorder.

Reflections

The patient is calm and very attentive. However, at some point, the patient becomes hypersensitive, and it becomes difficult to get the needed information from the patient. For instance, it was difficult to gather data related to patients' family history of mental illness. Any attempt made to get information on family psychiatric and psychosocial history proved futile. I faced several communication barriers, possibly because I did not employ the right strategy. Presented with a similar situation in the future, I will employ therapeutic communication strategies such as the use of open-ended questions, allowing sufficient time to communicate with the patient, and assessing both verbal and nonverbal patient communication needs. According to Rønning and Bjørkly (2019), therapeutic communication enables the patient to feel safer and more comfortable. Creating an environment that promotes openness and trust creates a conducive environment that gives a patient the best experience possible, enabling them to respond to even sensitive questions. I will definitely employ this strategy to aid in gathering as much information as possible and enhancing patient outcomes.

References

Carpenter Jr, W. T. (2021). How the diagnosis of schizophrenia impeded the advance of knowledge (and what to do about it).

Johnson, S. U., Ulvenes, P. G., Øktedalen, T., & Hoffart, A. (2019). Psychometric properties of the general anxiety disorder 7-item (GAD-7) scale in a heterogeneous psychiatric sample. Frontiers in psychology, 10, 1713.

Kessing, L. V., González-Pinto, A., Fagiolini, A., Bechdolf, A., Reif, A., Yildiz, A., ... & Vieta, E. (2021). DSM-5 and ICD-11 criteria for bipolar disorder: Implications for the prevalence of bipolar disorder and validity of the diagnosis–A narrative review from the ECNP bipolar disorders network. European Neuropsychopharmacology, 47, 54-61.

Rønning, S. B., & Bjørkly, S. (2019). The use of clinical role-play and reflection in learning therapeutic communication skills in mental health education: an integrative review. Advances in medical education and practice, 10, 415.

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: implications for clinical practice. Frontiers in psychiatry, 450.

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