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Week 9: Comprehensive Psychiatric Evaluation and Patient Case Presentation

College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

CC (chief complaint):  “I have issues with mood swings and anger

HPI: A.R is a 43 years old Caucasian female who was interview for medication maintenance.  The visit was done via telephone due to Covid-19 restriction.  Patient provided verbal consent.  She was informed of the limits of confidentiality in this setting, reporting requirements in the context of child and elder abuse and of interventions taken for suicidal/homicidal intent. 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 4“ I struggles with mood swing and anger”. Sleep: She has ome nightmares about abuse she endures years ago, can wake up crying. She has problems staying asleep, but when she does not sleep, she still stays in bed. Never sleeps a complete night. Appetite- She stated that she stages when she overeat to occur her feelings, “I am overweight now due to that, this is the biggest I have ever been”. She mentioned that she has always been heavy, and her sisters are very thin, her aunts another are thin, denies eating disorder but has struggled.. Hallucination- She denies hallucination and suicidal ideation.  Depression– When 10 is the worse on the scale of 1-10, she rates her depression to 7-8. Anxiety- She rates her anxiety 5 with tense, palm sweating, tachycardia, and does not want to be around others, hates going to group for probation, and would rather be in larger crowd on several occasions, on the scale of 1-10, when 10 is the worse.  Mania- She admits she has burst of energy and lives with little sleep, can be in great mood then down in the dumps. She said her family would call it mania, she admits to reckless behaviors, risky behaviors or being foolish,. Denies gambling and but admits to excessive spending when she had a job. Physical aggression or anger-She is currently on probation for aggravated assault. “I get so easily agitated, but I’m working hard on not responding the way I did in the past.” She used to be on Effexor, but she been off it since 2016.  She mentioned that Effexor is the only thing that has ever worked for her.  She has a traumic history of abuse when she was little by her step-grandfather. He passed away.  “It doesn’t seem to affect me.  I blocked it up, but my husband tell me I cry in my sleep and so I must be experiencing it then”.

 

Past Psychiatric History:

• General Statement: Patient seek help due to her concern about her mood and anger. She used to be on medication, but she have not taken any medication since 2016.
• Caregivers: Self
• Hospitalizations: One time in 2013
• Medication trials: Effexor, Trazodone, and Clonazepam.
• Psychotherapy or Previous Psychiatric Diagnosis: She was getting treatment for bipolar and depression with Effexor, but she stopped taking her medication in 2016.

Substance Current Use and History:  Previous hx of methamphetamine from age 18.

Family Psychiatric/Substance Use History:  No family hx of sudden death before age 30. Paternal cousin had 3 daughters and they all committed suicide. Mother has 4 sisters, and they all take medications for mental health except her mother.

Psychosocial History: Patient was raised by both parent. Both still alive, and she currently lives with them. She is the middle child from the family of 3 girls.  She got her GED, and also did cosmology and CNA.  She is currently married and this is his second marriage.  She is currently unemployed, seeking for job.  She worked at convenience store 3 years ago, and also worked at Sundown Rance as an assistance counselor for over 12 years.  She is on probation until 2030 for aggravated assault with deadly weapon.  No military history,

Medical History: Hypertension, Tubal ligation, C/S, back injury from a previous car accident.

 

 

• Current Medications: Amlodipine, and another medication she does not recall the name
• Allergies: Abilify

• Reproductive Hx: She has 4 children.  All grown and on their own.  LMP: April , 2022

ROS:

• GENERAL: Patient reports weight gain, some fatigue.
• HEENT: Denies any vision, hearing or head injuries.
• SKIN: Denies redness, or rash from her previous medication
• CARDIOVASCULAR: Denies chest pain or edema
• RESPIRATORY: No shortness of breath
• GASTROINTESTINAL: Denies Abdominal pain, nausea, or constipation
• GENITOURINARY: Denies frequency, or dysuria.
• NEUROLOGICAL: Denies numbness or tingling. No headaches
• MUSCULOSKELETAL: No muscle cramps
• HEMATOLOGIC: Denies anemia, or hx of bleeding disorders.
• PSYCHITRIC: Depression and anxiety reported. No recent suicidal ideation or hallucination.

 

• Physical exam: N/A with telephone interview

General: Patient is alert and oriented X4.  She remained calm and was cooperative throughout the section.

 

Diagnostic results: Not applicable

 

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—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

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: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection . You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

 

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).

References

Week 9: Comprehensive Psychiatric Evaluation and Patient Case Presentation

College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

 

CC (chief complaint):  “I have issues with mood swings and anger

HPI: A.R is a 43 years old Caucasian female who was interviewed for medication maintenance.  The visit was done via telephone due to the Covid-19 restriction.  The patient provided verbal consent.  She was informed of the limits of confidentiality in this setting, reporting requirements in the context of child and elder abuse, and interventions taken for suicidal/homicidal intent. 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 4″ I struggles with mood swing and anger”. Sleep: She has some nightmares about the abuse she endured years ago, and can wake up crying. She has problems staying asleep, but when she does not sleep, she still stays in bed. Never sleeps a complete night. Appetite- She stated that she stages when she overeats to occur her feelings, “I am overweight now due to that, this is the biggest I have ever been”. She mentioned that she has always been heavy, and her sisters are very thin, her aunts and another are thin, denies an eating disorder but has struggled. Hallucination- She denies hallucination and suicidal ideation.  Depression– When 10 is the worse on a scale of 1-10, she rates her depression to 7-8. Anxiety- She rates her anxiety 5 with tension, palm-sweating, tachycardia, does not want to be around others, hates going to a group for probation, and would rather be in a larger crowd on several occasions, on a scale of 1-10, when 10 is the worse.  Mania– She admits she has a burst of energy and lives with little sleep, can be in a great mood then down in the dumps. She said her family would call it mania, she admits to reckless behaviors, risky behaviors, or being foolish. Denies gambling but admits to excessive spending when she had a job. Physical aggression or anger-She is currently on probation for aggravated assault. “I get so easily agitated, but I’m working hard on not responding the way I did in the past.” She used to be on Effexor, but she has been off it since 2016.  She mentioned that Effexor is the only thing that has ever worked for her.  She has a traumatic history of abuse from when she was little by her step-grandfather. He passed away.  “It doesn’t seem to affect me.  I blocked it up, but my husband tells me I cry in my sleep and so I must be experiencing it then”.

Past Psychiatric History:

• General Statement: The patient seeks help due to her concern about her mood and anger. She used to be on medication, but she have not taken any medication since 2016.
• Caregivers: Self
• Hospitalizations: One time in 2013
• Medication trials: Effexor, Trazodone, and Clonazepam.
• Psychotherapy or Previous Psychiatric Diagnosis: She was getting treatment for bipolar and depression with Effexor, but she stopped taking her medication in 2016.

Substance Current Use and History:  Previous hx of methamphetamine from age 18.

Family Psychiatric/Substance Use History:  No family hx of sudden death before age 30. Paternal cousin had 3 daughters and they all committed suicide. Mother has 4 sisters, and they all take medications for mental health except her mother.

Psychosocial History: Patient was raised by both parent. Both still alive, and she currently lives with them. She is the middle child from the family of 3 girls.  She got her GED, and also did cosmology and CNA.  She is currently married and this is his second marriage.  She is currently unemployed, seeking for job.  She worked at convenience store 3 years ago, and also worked at Sundown Rance as an assistance counselor for over 12 years.  She is on probation until 2030 for aggravated assault with deadly weapon.  No military history,

Medical History: Hypertension, Tubal ligation, C/S, back injury from a previous car accident.

• Current Medications: Amlodipine, and another medication she does not recall the name
• Allergies: Abilify

• Reproductive Hx: She has 4 children.  All grown and on their own.  LMP: April , 2022

ROS:

• GENERAL: The patient reports weight gain, some fatigue.
• HEENT: Denies any vision, hearing or head injuries.
• SKIN: Denies redness, or rash from her previous medication
• CARDIOVASCULAR: Denies chest pain or edema
• RESPIRATORY: No shortness of breath
• GASTROINTESTINAL: Denies Abdominal pain, nausea, or constipation
• GENITOURINARY: Denies frequency, or dysuria.
• NEUROLOGICAL: Denies numbness or tingling. No headaches
• MUSCULOSKELETAL: No muscle cramps
• HEMATOLOGIC: Denies anemia, or hx of bleeding disorders.
• PSYCHITRIC: Depression and anxiety reported. No recent suicidal ideation or hallucination.
• Physical exam: N/A with telephone interview

General: Patient is alert and oriented X4.  She remained calm and was cooperative throughout the section.

 

Diagnostic results: Not applicable

Assessment

Mental Status Examination:

The patient is a 43-year-old Caucasian female. She cooperates throughout the telephone interview. She answers the questions logically, and her speech is coherent. However, during the interview, her voice is shaky which indicates that she could be tensed. She has a good memory span and seems to be in control of her thought process. She has a clear memory as well. She varies her tone accordingly.

Differential Diagnoses:

Based on the patient’s medical history and clinical manifestation, the three differential diagnoses that can be made include bipolar disorder, major depressive disorder, and post-traumatic stress disorder.

Bipolar 1 Disorder

            Bipolar 1 disorder is the first differential diagnosis based on the patient’s health history as well as clinical manifestation. Bipolar 1 is a mood disorder where the patients experience mood changes, manic and depressive episodes that not only affect one’s life negatively but also result in a burden of care. The DSM-5 criteria require that for a patient to be diagnosed with bipolar 1 disorder, they must have at least one manic episode lasting at least a week (Mousavi et al., 2021). Besides increased energy, the patient should also show three or four of the following symptoms: decreased sleep, agitation, risk-taking behaviors, racing thoughts, pressured speech, and heightened activity. The patient has a history of bipolar, she has been having problems falling asleep, has been experiencing episodes of mania, and is on probation until 2030 for assault.

Major Depressive Disorder

            Major depressive disorder is the patient’s second differential diagnosis. For individuals to be diagnosed with major depressive disorder, based on the DSM-5 criteria, they must demonstrate a depressed mood, poor feeding habits, poor sleeping habits, feeling tensed, low energy levels, loss of interest in activities they once enjoyed and poor concentration (Hasin et al., 2018). The patient rates her depression on a scale of 10 at 7-8, she never sleeps for a complete night and has been overfeeding to counter her feelings which have made her overweight.

Post Traumatic Stress Disorder                       

            The third differential diagnosis is a post-traumatic stress disorder. Post-traumatic stress disorder refers to a psychiatric disorder that presents among individuals that have gone through traumatic events in their lives such as assault, war, rape, or even violence. The DSM-5 criteria for the diagnosis of PTSD are that patients must show four cluster symptoms which are intrusion symptoms, reactive symptoms, avoidance symptoms as well as arousal symptoms (American Psychiatric Association, 2013). The patient has a history of abuse from her step-grandfather but she claims that it does not affect her as she blocked it. However, the husband keeps on telling her that she cries in her sleep. The patient, therefore, portrays reactive and intrusion symptoms by crying at night which shows she is responding to the abuse trauma. She shows avoidance symptoms by claiming that the abuse does not affect her and that she blocked it.

 

Reflection

The fact that the interview was done on the telephone, limits the healthcare practitioner’s actions due to the physical proximity barrier.

Nonetheless, if I were to meet the patient again, physically, I would create a safe environment for her to express herself with ease and assurance of care and empathy.

I would educate the patient on the importance of adherence to medication following her history of stopping her medication for depression and bipolar in 2016. I would make her understand that non-compliance with drug therapy could result in a relapse of the symptoms or worse still, adverse effects.

Legal and Ethical Issues

An ethical issue that would arise when managing the patient’s case is her history of stopping medication. It would be vital to note that a patient should take medication as per the instructions of the physicians to promote well-being and remission of symptoms.

The patient should follow up after four weeks to monitor her health and reaction to the medication.

 

References

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

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA psychiatry, 75(4), 336-346.

Mousavi, N., Norozpour, M., Taherifar, Z., Naserbakht, M., & Shabani, A. (2021). Bipolar I disorder: a qualitative study of the viewpoints of the family members of patients on the nature of the disorder and pharmacological treatment non-adherence. BMC psychiatry, 21(1), 1-11.