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Comprehensive Psychiatric Evaluation and Patient Case Presentation

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Week 7: Comprehensive Psychiatric Evaluation and Patient Case Presentation

College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

CC (chief complaint):  “I keep having mood swing and I think is affecting my children”

HPI: S.F is 36 years old Hispanic female.  She was interviewed via telehealth due to COVID-19 restrictions.  She seeked for help because she believes her mood swing is affecting her relationship with her children.  She said that she never want them to feel like they are the reason she acts the way she does.  She was asked about symptoms she been having, her current mood on the scale of 1 to 10, when 10 is the best mood,  She rates her mood 3 “ It fluctuates, I can be happy then sad, it is annoying, I ask myself why I am acting like this”. Sleep: She said that she has nightmares almost every night about being chased.  She has problem falling asleep and staying asleep.  Appetite- She eats really good sometimes, the wont eat at all.  He weight fluctuates up and down, but no history of eating disorder. Hallucination- She said sometimes she can see shadow out the corner of her eyes, and sometimes she can still hear her dad taling to her and he died in 2010.  Depression– When 10 is the worse on the scale of 1-10, she rates her depression to 10. Anxiety- She rates her anxiety 10 on several occasions, on the scale of 1-10, when 10 is the worse.  Mania- She admits she has a ton of energy at times and is up late cleaning, then can’t go to sleep before she knows she has been up all night. She denies suicidal ideations. Denies grandiosity or need for less sleep, reckless behaviors, risky behaviors or being foolish. Denies gambling and excessive spending.  She was on psychiatric medications, but she thought she could make it off medication for her mental health, but she now knows she needs to resume medications after nearly 6 years. She denies plans to harm herself or others but does have concerns that the person who murdered her father has never been located and wonders if any of the other member of her family could be in danger.

Past Psychiatric History:

  • General Statement: Patient seek help due to her concern that her mood swing affects her relationship with her children.
  • Caregivers: Self
  • Hospitalizations: None
  • Medication trials: Celexa, Trazodone, and Lithium. They were effective, but she decided to stop taking them 6 years ago.
  • Psychotherapy or Previous Psychiatric Diagnosis: She was diagnosed with bipolar. She was been managed with medications, until she decided to stop all her medications.

Substance Current Use and History:  

Alcohol-yes

Tetrahydrocannabinol– yes

Amphetamines – yes

Cocaine – yes

Heroin/Opiates – yes

Hallucinogens – yes

Family Psychiatric/Substance Use History:  No none family history of suicide or sudden death before age 30.  Also no known family history of mental illness.

Psychosocial History: Patient was raised by both parents.  She has 2 brothers and 1 sister; she is second in birth order. She said her mother was a hard worker but is not a house wife and her father was also a good man and hard worker but he was murdered in 2010.  She finished at 9th grade in school, but she got her GED.  .” “I applied for FASFA and got it. I’m looking at going into Business Administration School. She has never been married, but in a relationship with the father of her las child.  She lives with her mother and 3 youngest children.  She likes spending time with her children, and she used to love skating She is currently employed with United Framing since March of this year, has done construction/carpentry. Her longest job held was 3 years doing house keeping.  Sonia is on parole for manufacturing/delivery of a controlled substance. She is off parole 11/22/2031. Her parole officer is Sundae Webb. Sonia was incarcerated 5.5 years. She reported Texas Department of Criminal Justice (TDCJ) incarceration 2013-2014. When released in 2014, continued to get in trouble and would get locked in county jail, then released, then back. She reported she was sent back to TDCJ in 2016.

Medical History: Hypertension, Hypothyroidism, Right ankle fx, Abdominal hernia mesh,

 

  • Current Medications: Amlodipine 5 mg daily, Levothyroxine 0.15 mg Q morning, HTCZ 12.5 mg daily, Oxybutynin 5 mg BID.
  • Allergies: NKA
  • Reproductive Hx: She has 6 children, 3 living with her and 3 out of the house.

ROS:

  • GENERAL: Patient reports weight up and down.
  • HEENT: No vision problem,  No hearing loss or congestion.
  • SKIN: Denies current rash or history of rash from her previous medication
  • CARDIOVASCULAR: Denies chest pain or edema
  • RESPIRATORY: Denies SOB
  • GASTROINTESTINAL: No nausea or vomiting, Denies abdominal discomfort.
  • GENITOURINARY: Denies urgency, frequency or dysuria.
  • NEUROLOGICAL: No numbness or tingling reported, No paralysis.
  • MUSCULOSKELETAL: No muscle pain
  • HEMATOLOGIC: Denies anemia, or hx of bleeding disorders.
  • LYMPHATICS: Denies lymp node problems
  • PSYCHITRIC: Reports depression and anxiety . No recent suicidal thoughts

 

  • Physical exam: Weight 183 lbs, HT: 71 inches

Diagnostic results: PHQ-9 (Patient Health Questionnaire-9): This is used for screening patient for depression. The PHQ-9 is made up of nine questions that are only applicable to the last two weeks such as a nhedonia, depressed mood, sleeping problems, fatigue, appetite changes, feelings of worthlessness, concentration problems, psychomotor agitation/retardation, and suicide thoughts (Dadfar et al., 2021).

 

Assessment

Mental Status Examination:  For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses:  What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority BIPOLAR to lowest priority other two. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis

Reflections: 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.).

Legal and ethical issues.

References

 Week 7: Comprehensive Psychiatric Evaluation and Patient Case Presentation

College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

CC (chief complaint):  “I keep having mood swing and I think is affecting my children”

HPI: S.F is 36 years old Hispanic female.  She was interviewed via telehealth due to COVID-19 restrictions.  She sought help because she believes her mood swing is affecting her relationship with her children.  She said that she never wants them to feel like they are the reason she acts the way she does.  She was asked about symptoms she has been having, her current mood on a scale of 1 to 10, when 10 is the best mood,  She rates her mood 3 ” It fluctuates, I can be happy then sad, it is annoying, I ask myself why I am acting like this”. Sleep: She said that she has nightmares almost every night about being chased.  She has a problem falling asleep and staying asleep.  Appetite– She eats well sometimes, and the won’t eat at all.  Her weight fluctuates up and down, but no history of an eating disorder. Hallucination– She said sometimes she can see a shadow out the corner of her eyes, and sometimes she can still hear her dad talking to her and he died in 2010.  Depression– When 10 is the worse on a scale of 1-10, she rates her depression 10. Anxiety– She rates her anxiety 10 on several occasions, on a scale of 1-10 when 10 is the worse.  Mania- She admits she has a tone of energy at times and is up late cleaning, they can’t go to sleep before she knows she has been up all night. She denies suicidal ideations. Denies grandiosity or need for less sleep, reckless behaviors, risky behaviors, or being foolish. Denies gambling and excessive spending.  She was on psychiatric medications, but she thought she could make it off medication for her mental health, but she now knows she needs to resume medications after nearly 6 years. She denies plans to harm herself or others but does have concerns that the person who murdered her father has never been located and wonders if any of the other members of her family could be in danger.

 

Past Psychiatric History:

  • General Statement: Patient seek help due to her concern that her mood swing affects her relationship with her children.
  • Caregivers: Self
  • Hospitalizations: None
  • Medication trials: Celexa, Trazodone, and Lithium. They were effective, but she decided to stop taking them 6 years ago.
  • Psychotherapy or Previous Psychiatric Diagnosis: She was diagnosed with bipolar. She was been managed with medications, until she decided to stop all her medications.

Substance Current Use and History:  

Alcohol-yes

Tetrahydrocannabinol– yes

Amphetamines – yes

Cocaine – yes

Heroin/Opiates – yes

Hallucinogens – yes

Family Psychiatric/Substance Use History:  No none family history of suicide or sudden death before age 30.  Also no known family history of mental illness.

Psychosocial History: Psychosocial History: The patient was raised by both parents.  She has 2 brothers and 1 sister; she is second in birth order. She said her mother was a hard worker but is not a housewife and her father was also a good man and hard worker but he was murdered in 2010.  She finished at 9th grade in school, but she got her GED.  .” “I applied for FASFA and got it. I’m looking at going into Business Administration School. She has never been married but is in a relationship with the father of her last child.  She lives with her mother and 3 youngest children.  She likes spending time with her children, and she used to love skating She is currently employed with United Framing since March of this year, and has done construction/carpentry. Her longest job held was 3 years doing housekeeping.  Sonia is on parole for manufacturing/delivery of a controlled substance. She is off parole on 11/22/2031. Her parole officer is Sundae Webb. Sonia was incarcerated for 5.5 years. She reported Texas Department of Criminal Justice (TDCJ) incarceration 2013-2014. When released in 2014, continued to get in trouble and would get locked in county jail, then released, then back. She reported she was sent back to TDCJ in 2016.

Medical History: Hypertension, Hypothyroidism, Right ankle fx, Abdominal hernia mesh,

 

  • Current Medications: Amlodipine 5 mg daily, Levothyroxine 0.15 mg Q morning, HTCZ 12.5 mg daily, Oxybutynin 5 mg BID.
  • Allergies: NKA
  • Reproductive Hx: She has 6 children, 3 living with her and 3 out of the house.

ROS:

  • GENERAL: The patient reports weight up and down.
  • HEENT: No vision problem, No hearing loss or congestion.
  • SKIN: Denies current rash or history of rash from her previous medication
  • CARDIOVASCULAR: Denies chest pain or edema
  • RESPIRATORY: Denies SOB
  • GASTROINTESTINAL: No nausea or vomiting, Denies abdominal discomfort.
  • GENITOURINARY: Denies urgency, frequency or dysuria.
  • NEUROLOGICAL: No numbness or tingling reported, No paralysis.
  • MUSCULOSKELETAL: No muscle pain
  • HEMATOLOGIC: Denies anemia, or hx of bleeding disorders.
  • LYMPHATICS: Denies lymph node problems
  • PSYCHIATRIC: Reports depression and anxiety . No recent suicidal thoughts

 

  • Physical exam: Weight 183 lbs, HT: 71 inches

Diagnostic results: PHQ-9 (Patient Health Questionnaire-9): This is used for screening patient for depression. The PHQ-9 is made up of nine questions that are only applicable to the last two weeks such as a nhedonia, depressed mood, sleeping problems, fatigue, appetite changes, feelings of worthlessness, concentration problems, psychomotor agitation/retardation, and suicide thoughts (Dadfar et al., 2021).

Assessment

Mental Status Examination:

The patient is a 36-year-old Hispanic female who appears the stated age. She is cooperative throughout the interview but in some instances seems lost in thought. She has a clear speech and varies her tone normally. She however seems moody and unable to get humor even when the therapist cracks a joke. She has no signs of hallucinations and has a good concentration span. Her speech and thought processes are coherent.

Differential Diagnoses:

Based on the patient’s assessment and medical history, the differential diagnoses are bipolar disorder, major depressive disorder, and substance-induced mood disorder.

Bipolar Disorder

Bipolar disorder is the priority differential diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) define bipolar as a disorder that causes an extreme fluctuation of a person’s energy, mood, and ability to function (American Psychiatric Disorder, 2013). People living with the condition experience periods of feeling excited, overactive, delusions, mani, and other times they experience low moods of hopelessness and sadness. The patient acknowledges significant episodes of moodiness and other times overactivity where she does her cleaning throughout the night. More so, she was previously diagnosed with bipolar and put on medications until she decided to stop which could have resulted in a relapse of the bipolar symptoms.

 

 

Major Depressive Disorder

The second differential diagnosis is major depressive disorder (MDD). The DSM-5 diagnostic criteria require that for patients to be diagnosed with MDD, they must show a minimum of five symptoms for at least two weeks. The symptoms include depressed mood, weight gain or loss, a loss of interest in once pleasurable activities, insomnia, guilt, decreased concentration, and agitation (Mullen, 2018). The patient confirms having a depressed mood, is feeling some guilt about the effects of her moodiness on her children, and has been having insomnia, appetite problems as well as agitation. More so, the patient rates her depression as 10 on a scale of 1 to 10.

Substance-Induced Mood Disorders

The third differential diagnosis is substance-induced mood disorders. Substance-induced disorders are anxiety, depression, a psychotic or manic symptom that occur as a physiological effect of using substances (Revadigar & Gupta, 2021).  The disorders may develop during the active period of substance abuse, or during the withdrawal period. Vieta et al. (2018) assert that bipolar and depression commonly co-occur with substance use disorders. The most associated drugs with the disorder are cocaine and opioids. Based on the patient’s drug history, she uses cocaine, heroin, hallucinogens, alcohol, tetrahydrocannabinol, and amphetamines which supports the diagnostic criteria.

 

 

Reflections:

What I would do differently is to encourage a patient-directed conversation to give her adequate time to express herself, and express her feelings as a way of enabling her to reflect on her actions, their impact on her children, and her desires as a mother.

Health promotion would be based on the importance of complying with medications to increase their effectiveness and prevent a relapse of the symptoms. I would also encourage the family to provide a strong support system, and better still recommend a rehabilitation program to encourage her to gradually stop substance use.

Legal and ethical issues.

The patient’s history brings out ethical and legal issues based on her history of substance use, non compliance with drugs, psychiatric history as well as comorbidities. Non-compliance with medication has been associated with adverse events as well as relapse of symptoms (Semahegn et al., 2018). The patient’s dependence on substances could affect her ability to comply with the pharmacological agents. Additionally, the drugs could interact making the medications less effective or causing unexpected effects . Her previous diagnosis with bipolar shows that she has been living with psychiatric issues that have not been managed effectively.

 

 

 

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Mullen S. (2018). Major depressive disorder in children and adolescents. The mental health clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275

Revadigar, N., & Gupta, V. (2021). Substance Induced Mood Disorders. In StatPearls [Internet]. StatPearls Publishing.

Semahegn, A., Torpey, K., Manu, A., Assefa, N., Tesfaye, G., & Ankomah, A. (2018). Psychotropic medication non-adherence and associated factors among adult patients with major psychiatric disorders: a protocol for a systematic review. Systematic reviews, 7(1), 10. https://doi.org/10.1186/s13643-018-0676-y

Vieta, E., Salagre, E., Grande, I., Carvalho, A. F., Fernandes, B. S., Berk, M., … & Suppes, T. (2018). Early intervention in bipolar disorder. American Journal of Psychiatry, 175(5), 411-426.