Nursing homework

week6hw.docx

Video notes:

The patient verbalized her belief that her employer intends to terminate her employment because he has romantic feelings toward her. She stated that she believes her boss is attracted to her based on the way he looks at her, despite both individuals being in committed relationships. When asked to elaborate on her reasoning, the patient stated, "Because I am a strong, confident, beautiful woman. Of course, that is why he wants to fire me." The patient appeared to attribute the potential termination to her employer's perceived romantic interest rather than her reported lack of sales over the past three weeks.

Additionally, the patient expressed that she is physically ill due to a "broken heart" and stated that she believes she has cancer. However, she acknowledged that she has not sought medical evaluation or received a formal diagnosis to support this belief. Because of her employer

Name: Ms. Fatima Branning

Gender: female

Age: 28 years old

T- 98.4 P- 82 R 18 124/74 Ht 5’0 Wt 118lbs

Background: Raised by parents, lives alone in Coronado, CA. Only child. Works as an

administrative assistance in car sales, has a bachelor’s in hospitality. Has medical history of

scoliosis, currently treated with chiropractic care. Guarded and declined to discuss past

psychiatric history. Denied family mental health issues, declined to allow you to speak to parents

for collaborative information. Allergies: latex; menses regular, no birth control

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

· Objective: What observations did you make during the psychiatric assessment? 

· Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

· Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

NRNPPRAC6635ComprehensivePsychiatricEvaluationTemplate12.docx

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Week 4: (Anxiety Disorder)

Anthony Silva

Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Professor Jennifer Goldsborough DNP

9/26/26

Subjective:

CC (chief complaint): “I’m really scared that if I tell people I’m gay, they will treat me differently.”

HPI: R.N. is a 19-year-old man, a Navy Reservist (Construction Mechanic, CM3), who has approximately two months of sadness, fear, and emotional distress due to being informed that he is being activated to go to deployment. He is having a hard time coming to terms with his sexuality and he has revealed it to no one other than this evaluator because he is afraid his unit will treat him differently; he also states that he hears homophobic words among service members, which is why he is afraid. He says, I am not comfortable telling anybody, and I have to go on tour, and I am angry about it. The severity is mild-moderate; the patient is functional but is not interacting with his peers, does not engage in any personal conversations, and his concentration and productivity in his part-time employment are significantly lower. Sleep (approximately 8 hours) and appetite intact; he withstands anhedonia, guilt, worthlessness, suicidal and homicidal ideation, self-mutilation, psychosis and mania.

Past Psychiatric History:

· General Statement: None; first evaluation.

· Caregivers (if applicable): independent adult, though parents remain supportive.

· Hospitalizations: None.

· Medication trials: None.

· Psychotherapy or Previous Psychiatric Diagnosis: None.

Substance Current Use and History: Not received; to be filled in at follow-up, alcohol use consideration military-service risk.

Family Psychiatric/Substance Use History: Not obtained; to be completed at follow-up

Psychosocial History: Resides in Columbus, Ohio with his dog; has no children; parents live in the area and are supportive; single; part-time construction work and reserve duty; no legal or trauma history.

Medical History: No chronic illness.

· Current Medications: None.

· Allergies: NKDA.

· Reproductive Hx: Not obtained; to be addressed as clinically indicated.

ROS:

· GENERAL: Denies fever/weight change; reports anxiety.

· HEENT: Denies visual/hearing changes, sore throat.

· SKIN: Denies rash or sweating.

· CARDIOVASCULAR: Denies chest pain/palpitations.

· RESPIRATORY: Denies dyspnea/cough.

· GASTROINTESTINAL: Denies nausea/appetite change.

· GENITOURINARY: Denies dysuria.

· NEUROLOGICAL: Denies headache; reports mild concentration difficulty.

· MUSCULOSKELETAL: Denies pain/stiffness.

· HEMATOLOGIC: Denies bruising/bleeding.

· LYMPHATICS: Denies swollen nodes.

· ENDOCRINOLOGIC: Denies temperature intolerance, polyuria.

Objective:

Physical exam: if applicable T 97.0°F, P 70, R 18, BP 116/68, Ht 5’9”, Wt 175 lb (BMI 25.8), all within normal limits. He looks his claimed age and compliant, but evidently nervous when talking about disclosure.

Diagnostic results: There are no standardized screening tools that have been implemented; GAD-7, PHQ-9, and a suicide risk screen will be used. Neither labs were ordered because there is no symptom of a medical contributor.

Assessment:

Mental Status Examination: Cooperative, groomed; speech normal. Mood scared and upset, affect anxious, slightly tearful, congruent. Thought process is linear; content is about disclosure/deployment fears, absent delusions. Denies hallucinations, suicidal/ homicidal ideation. Awareness, orientation 4/; memory intact; attention deficient. Good sense and perception.

Differential Diagnoses:

1. Adjustment disorder with mixed anxiety and depressed mood (F43.23), primary. Has to have an identifiable stressor, a onset within three months, and distress not attributable to another disorder (Keepers et al., 2024). His reactivation and hiding of his identity would be evident, as the new stressors would fall into this pattern; concealment is an established cause of chronic stress (Meyer, 2013).

2. Generalized anxiety disorder (F41.1). Has at least six months of excessive worry in several areas, and the symptoms are characterized. He is only concerned about deployment/disclosure, which has been two months long, and the sleep/appetite intact, which eliminates this on both duration and breadth.

3. major depressive disorder (F32.x). Needs five out of nine symptoms two weeks, such as depressed mood or anhedonia. The symptom threshold is not achieved as he has no anhedonia, change in appetite/sleep, or guilt.

4. Social anxiety disorder (F40.10). Has six months or longer of marked fear of social/performance situations. Its fear is not that of generalized evaluation but that of a particular disclosure in a hostile environment and the term is not met, so this is precluded at present.

Critical thinking: I contrasted his symptoms to the duration/breadth thresholds of the anxiety disorders and the number of symptoms in major depression; none were fulfilled. Adjustment disorder single was the most appropriate choice in case of a recent stressful event that had a proportionate and time-limited distress. Relevant positives: recognizable stressor, anxious/depressed, fear of disclosure, withdrawal, lack of concentration. Relevant negatives: no suicidal/homicidal thoughts, psychosis, history of psychiatric illness, or sleep/appetite loss.

Reflections:

Given a re-enactment of this session, I would ensure that I receive full substance use and family psychiatric history at intake, officially screen with the GAD-7 and PHQ-9 to establish a baseline of severity and conduct a full suicide risk assessment due to the high risk associated with concealment and minority stress (Meyer, 2013). I would also simply inquire about harassment, as he has heard derogatory language, as to whether he has been the one targeted.

Legal/ethical: Military confidentiality is limited by consent, even though the advice on the ramifications of sharing information before deployment is limited by fitness-for-duty and command-notification requirements, I would discuss such limits directly instead of assuming that civilian-confidentiality is relevant. I would neither advise nor discourage his disclosure to his unit as I would respect his personal autonomy and inform him of the Equal Opportunity channels in which he heard the harassment, but would not disclose his identity to him. I would also consider the ethical risk of over-medicalizing a normal adjustment response against the risk of under-treating a service member who has an adjustment reaction that is complicated by concealment.

Health promotion: The following factors are relevant: his age (19, emerging adult), no past history of psychiatric or medical problems, part-time-income socioeconomic status and reserve duty, and the stress of having a stigmatized identity in the military culture; at the same time, the race/ethnicity was not recorded. Since there are recorded mental health disparities and minority-related suicide risk linked to minority stress (Meyer, 2013), I would recommend him to LGBTQ-affirming, military-competent (Military OneSource, SPARTA), provide first-line cognitive-behavioral therapy (Walter et al., 2020), and regularly screen him on depression, anxiety, and substance use.

References

Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., ... & Medicus, J. (2024). The American Psychiatric Association practice guideline for the treatment of patients with borderline personality disorder. American Journal of Psychiatry, 181(11), 1024-1028. https://psychiatryonline.org/doi/full/10.1176/appi.ajp.24181010

Meyer, I. H. (2013). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. https://psycnet.apa.org/journals/sgd/1/S/3/

Walter, H. J., Bukstein, O. G., Abright, A. R., Keable, H., Ramtekkar, U., Ripperger-Suhler, J., & Rockhill, C. (2020). Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 59(10), 1107–1124. https://www.sciencedirect.com/science/article/pii/S089085672030280X