Week 7: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6645-19: Psychopathology and Diagnostic Reasoning
Subjective:
CC (chief complaint): “I can’t control my anger and usually yell at people”
HPI: B.M is a 29 year old caucacian male who reports that he often feels depressed, with decreased appetite (loss of 20 lbs. in several months), loss of energy, waking up nightly, frequent anger, daily verbal outbursts with yelling, screaming, and possible destruction of property, and is easily overwhelmed which triggers outbursts. He presented today on time via telephone. He was calm, cooperative and answers questions appropriately. Client appears reliable historian. Reports that he is not currently taking any medication. Client reports worsening insomnia, anger, and mood fluctuation. He stated “I just stay isolated, I have empty mood, no one calls me back, fiancée almost left me due to lack of impulse control” He reported daily verbal outbursts with yelling, screaming, and possible destruction of property, reports that’s why he lost his previous job. “I cannot control my anger. My sleep is horrible, I stay up all night playing video games”. He reported that whenever he get yell at, or if he don’t get answers right away, He usually have problems controlling his anger. He denies any suicidal ideation or self cut. For mania, he denies any symptoms of mania including abnormally and persistently elevated/irritable mood, and inflated self-esteem. He has problem falling asleep and staying asleep. He sometimes sleep about 3 to 4 hours at night. He reports loss of appetite, and only eats once a day. He admits loss of pressure in activities, feelings of guilt, worthlessness, helplessness, and hopelessness.
Review of System:
Psychitric: Patient reports feeling depressed, anger, and anxiety.
Repiratory: He denies any cough, or SOB
Cardiac: No chest pain reported
Past Psychiatric History:
- General Statement: Patient entered into treatment due to his impulsive problem and depressive symptoms. He want to find a good coping mechanism to deal with his problem to avoid getting in trouble.
- Caregivers (if applicable): None
- Hospitalizations: None
- Medication trials: Hydroxyzine 50 mg tab twice daily.
- Psychotherapy or Previous Psychiatric Diagnosis: Depression and PTSD
Substance Current Use and History: He smokes half a pack daily. He denies marijuana use or other illicit drugs.
Family Psychiatric/Substance Use History: His father has history of bipolar disorder, and both the father and mother are alcoholics. His brother died in 2017 from suicide.
Psychosocial History: Patient was born and raised in Greenville Texas. He has two older sisters and 2 younger brothers. He only talk to one of his sisters. His highest education was high school diploma. He currently lives with his fiancé and his three children ages 8, 6, and 3 years old. He currently employed as a construction worker by his neighbor. He denies any legal history, no military background. He likes to play video games. He practice Christianity. He was sexually assaulted by uncle when he was 13 years old, I did not say nothing about it, but he s currently in prison.
Medical History: N/A
- Current Medications: None
- Allergies: NKA
- Reproductive Hx: He currently has a fiancé and they are both sexually active..
Objective:
Psychiatric: Patient remain calm the whole evaluation.
Diagnostic results: N/A
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, pseudo hallucinations, 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 yo 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 in order of highest to lowest priority (Impulse-control disorder, depression, and chose one more) and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
Reflections: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Case Formulation and Treatment Plan:
Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
Week 7: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6645-19: Psychopathology and Diagnostic Reasoning
Subjective:
CC (chief complaint): “I can’t control my anger and usually yell at people”
HPI: B.M is a 29-year old caucasian male who reports that he often feels depressed, with decreased appetite (loss of 20 lbs. in several months), loss of energy, waking up nightly, frequent anger, daily verbal outbursts with yelling, screaming, and possible destruction of property, and is easily overwhelmed which triggers outbursts. He presented today on time via telephone. He was calm, cooperative, and answered questions appropriately. The client appears reliable historian. Reports that he is not currently taking any medication. The client reports worsening insomnia, anger, and mood fluctuation. He stated “I just stay isolated, I have empty mood, no one calls me back, fiancée almost left me due to lack of impulse control” He reported daily verbal outbursts with yelling, screaming, and possible destruction of property, reports that’s why he lost his previous job. “I cannot control my anger. My sleep is horrible, I stay up all night playing video games”. He reported that whenever he gets yelled at, or if he doesn’t get answers right away, He usually has problems controlling his anger. He denies any suicidal ideation or self-cut. For mania, he denies any symptoms of mania including abnormally and persistently elevated/irritable mood and inflated self-esteem. He has a problem falling asleep and staying asleep. He sometimes sleeps about 3 to 4 hours at night. He reports a loss of appetite and only eats once a day. He admits the loss of pressure in activities, feelings of guilt, worthlessness, helplessness, and hopelessness.
Review of System:
Psychitric: The patient reports feeling depressed, anger, and anxiety.
Repiratory: He denies any cough, or SOB
Cardiac: No chest pain reported
Past Psychiatric History:
- General Statement: The patient entered into treatment due to his impulsive problem and depressive symptoms. He wants to find a good coping mechanism to deal with his problem to avoid getting in trouble.
- Caregivers (if applicable): None
- Hospitalizations: None
- Medication trials: Hydroxyzine 50 mg tab twice daily.
- Psychotherapy or Previous Psychiatric Diagnosis: Depression and PTSD
Substance Current Use and History: He smokes half a pack daily. He denies marijuana use or other illicit drugs.
Family Psychiatric/Substance Use History: His father has a history of bipolar disorder, and both the father and mother are alcoholics. His brother died in 2017 from suicide.
Psychosocial History: The patient was born and raised in Greenville Texas. He has two older sisters and 2 younger brothers. He only talks to one of his sisters. His highest education level was high school diploma. He currently lives with his fiancé and his three children ages 8, 6, and 3 years old. He is currently employed as a construction worker by his neighbor. He denies any legal history, no military background. He likes to play video games. He practices Christianity. He was sexually assaulted by uncle when he was 13-years-old, though he did not say anything about it, but the uncle is currently in prison.
Medical History: N/A
- Current Medications: None
- Allergies: NKA
- Reproductive Hx: He currently has a fiancé and they are both sexually active.
Objective:
Psychiatric: Patient remained calm throughout the whole evaluation.
Diagnostic results: N/A
Assessment:
Mental Status Examination:
The patient is a 29-year-old Caucasian male who appears through a telephone interview with anger issues. Despite being unable to control his anger, the patient confirms that he also yells at people. Throughout the interview, the patient seems depressed, out of touch, and most importantly has anger outbursts. He demonstrates a logical and coherent thought process. Throughout the interview, the patient seems to have a short concentration as his mind seems to sway away from the interview to other things. The patient however denies any suicidal ideations.
Differential Diagnoses:
Based on the patient’s clinical manifestation and psychiatric manifestation, the three differential diagnoses that would be suitable for the patient case would be impulse–control disorder, depression and bipolar 2 disorder.
Impulse-control disorder
The priority diagnosis for the patient is impulse-control disorder. According to the DSM-5 diagnostic criteria, impulse-control disorder is manifested by either physical or verbal aggression (American Psychiatric Association, 2013). Patients should show temper tantrums, arguments, tirades, or physical aggression towards other people, property, or animals. The patient’s subjective information supports the diagnosis as the patient confirmed having daily verbal outbursts, he screams and yells and destroys property.
Major depressive disorder
The second patient’s diagnosis is a major depressive disorder. The DSM-5 diagnostic criteria for the major depressive disorder include characteristics like poor sleeping patterns, loss of appetite, loss of pleasure in once pleasurable activities, depressed mood, feelings of hopelessness and helplessness as well as low energy levels for at least two weeks (Hasin et al., 2018). The patient claims that he feels depressed, has lost 20 lbs over the last several months, sleeps for only 3 to 4 hours a night, and experiences feelings of hopelessness, helplessness, and guilt.
Bipolar 2
The third differential diagnosis is bipolar 2 disorder. Bipolar 2 disorder is a condition where a person has at least one depressive episode and at atleast one hypomanic episode (Nierenberg, 2019). In patints with bipolar 2, the up moods usually never reach full blown mania. Based on the patient’s subjective information, he seems to be having a combination of both depressive and hypomania symptoms. He confirms to being depressed and equally at times full of energy to game all night.
Reflections:
What I would do differently with the patient would be to conduct a face-face interview or through a video call to have a closer look of the patient’s body language and display of emotions.
A social determinant of health from the HealthyPoeple 2030 website that would apply to this patient case would be the social and community context. The social determinant of health requires that people maintain healthy relationships with each other to promote their well-being. The patient has a problem with anger outbursts which would hinder his ability to have cordial relations with others. He would therefore need to access therapy to improve his emotional control and reduce his verbal and physical aggression.
One health promotion activity that I would recommend for the patient would be patient education on the importance of seeking promptly seeking medical attention. Prompt medical care is likely to ensure that the patient’s symptoms are well managed to prevent health deterioration while at the same time lowering the possibility of the patient getting into trouble with others and even with the authority.
Case Formulation and Treatment Plan:
The patient’s medical history indicates that he is on medication (Hydroxyzine 50 mg) daily. Therefore, it would be vital to use a combination of both medication and psychotherapy which nursing literature has shown to be an effective modality of managing psychiatric illnesses. Antipsychotic drugs will help to alleviate depressive symptoms, appetite issues, and agitation. Psychotherapy will help the patient develop better anger management strategies reducing cases of verbal and physical aggression.
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.
Nierenberg, A. A. (2019). Bipolar II disorder is NOT a myth. The Canadian Journal of Psychiatry, 64(8), 537-540.