Week 4: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Tochukwu Odiegwu
College of Nursing-PMHNP, Walden University
PRAC 6645-19: Psychotherapy with Multiple Modalities Practicum
Dr. Lavon Williams
Subjective:
CC: “ I feel so depress, moody and angry everytime and it keep getting worse”
HPI: D.J is a 40 years old Caucacian male with past psychiatric history. He presented with feeling depress and always gets angry and moody. He had a session of Complete Psychitric Evalution through telehealth interview. He denies any suicidal thoughts, hallucination and nightmares. He sleeps about 4 to 5 hours a night. He currently has gun, but is locked up and only use it when he wants to teach his son. He denies any eating disorder, but he mentioned that he don’t eat for enjoyment of it, but eats to stay alive. Moreover, don’t feel hungry most of the time. He rates his depression on the scale of 1-10(10 being the worse) to be 8. Also his anxiety on the scale of 1-10(10 being worse) to be 8. He denies any gradiosity or euphoria. No excessive spending or gamblings. He denied having a supernatural power or He admits he has tons of energy and usually stay up at night working and cleaning his garage. He used to be on psychritri medication, but stopped taking it long time ago. His wife adviced him to seek for help due to how it affects their marriage and children.
ROC
Cadiac: Patient denied chect pain or palpitation
Respiratory: No SOB reported.
Psychitric: Patient reports feeling moody and depress. Denies suicidal thoughts
Past Psychiatric History:
- General Statement: Patient entered treatment due to his depression and mood behavoir. He need help to help him get back to normal for the sake of his family.
- Caregivers (if applicable): N/A
- Hospitalizations: N/A
- Medication trials: He was on Welbutrin with unknown mg
- Psychotherapy or Previous Psychiatric Diagnosis: Bipolar type 1, Depression, Anxiety.
Substance Current Use and History: Alcohol occasionally, Marijuana, Smoke 1 ack of cigarrete/day, and history of cocaine use.
Family Psychiatric/Substance Use History: N/A, no sudden or unknown for any member of his family
Psychosocial History: Patient was born and raised in in Canton Texas, but currently living in Tyler Texas. He got his high school diploma and got a job at warehouse. He is currently married and has 4 children, three is currently living with him and his wife. He is in good relationship with his children. His father and mother is still living and he has one older brother. He is currently employed. He was sexually and physically abused when he was 9 years old and his parent were aware. He went through therapy that period. He used to like hunting, but not anymore. He doesn’t find anything to interest him. No past legal issues.
Medical History: No medical history
- Current Medications: N/A
- Allergies: NKA
- Reproductive Hx: He has a wife and they are sexually active
Objective:
Psychitric: Patient displays anxiety and depression.
Diagnostic results: N/A
Weight: 150 lbs, and Height: 6 feets
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: Provide a minimum of three possible diagnoses in order of highest to lowest priority 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
five scholarly resources to support your assessment and diagnostic reasoning.
Week 4: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Tochukwu Odiegwu
College of Nursing-PMHNP, Walden University
PRAC 6645-19: Psychotherapy with Multiple Modalities Practicum
Dr. Lavon Williams
Subjective:
CC: ” I feel so depressed, moody, and angry every time and it keeps getting worse”
HPI: D.J is a 40 years old Caucasian male with a past psychiatric history. He presented with feeling depressed and always gets angry and moody. He had a session of Complete Psychiatric Evaluation through a telehealth interview. He denies any suicidal thoughts, hallucinations, and nightmares. He sleeps about 4 to 5 hours a night. He currently has a gun but is locked up and only uses it when he wants to teach his son. He denies any eating disorder, but he mentioned that he doesn’t eat for the enjoyment of it, but eats to stay alive. Moreover, don’t feel hungry most of the time. He rates his depression on a scale of 1-10(10 being the worse) to 8. Also, his anxiety on a scale of 1-10(10 being worse) is 8. He denies any grandiosity or euphoria. No excessive spending or gambling. He denied having a supernatural power or He admits he has tons of energy and usually stays up at night working and cleaning his garage. He used to be on psychiatric medication but stopped taking it a long time ago. His wife advised him to seek help due to how it affects their marriage and children.
ROC
Cardiac: The patient denied chect pain or palpitation
Respiratory: No SOB reported.
Psychiatric: The patient reports feeling moody and depressed. Denies suicidal thoughts
Past Psychiatric History:
- General Statement:The patient started treatment due to his depression and mood behavoir. He needs help to help him get back to normal for the sake of his family.
- Caregivers (if applicable): N/A
- Hospitalizations: N/A
- Medication trials: He was on Welbutrin with unknown mg
- Psychotherapy or Previous Psychiatric Diagnosis: Bipolar type 1, Depression, Anxiety.
Substance Current Use and History: Alcohol occasionally, Marijuana, SmokeS 1 pack of cigarrete/day, and has a history of cocaine use.
Family Psychiatric/Substance Use History: N/A, no sudden or unknown for any member of his family
Psychosocial History: The patient was born and raised in Canton Texas, but currently living in Tyler Texas. He got his high school diploma and got a job at a warehouse. He is currently married and has 4 children, three are currently living with him and his wife. He is in a good relationship with his children. His father and mother are still living and he has one older brother. He is currently employed. He was sexually and physically abused when he was 9 years old and his parent was aware. He went through therapy during that period. He used to like hunting, but not anymore. He doesn’t find anything to interest him. No past legal issues.
Medical History: No medical history
- Current Medications: N/A
- Allergies: NKA
- Reproductive Hx: He has a wife and they are sexually active
Objective:
Psychitric: Patient displays anxiety and depression.
Diagnostic results: N/A
Weight: 150 lbs, and Height: 6 feets
Assessment:
Mental Status Examination:
The patient is a 40-year-old Caucasian male who confirms having feelings of depression, moodiness, anger, and irritation which he says it’s getting worse through a telehealth interview. He has a coherent and logical speech. He answers the questions logically. He demonstrates a correct thought process and is in control of his feelings. He has an impaired memory and a short concentration span that he demonstrates throughout the interview.
Differential Diagnoses:
Based on the patient’s psychiatric history and symptoms, the three differential diagnoses that would be made are major depressive disorder, bipolar disorder, and generalized anxiety disorder.
Major Depressive Disorder
Major depressive disorder is the priority diagnosis for the patient. The DSM-5 diagnostic criteria for major depressive disorder requires that patients show a myriad of symptoms ranging from a depressed mood, loss of interest in once pleasurable activities, poor feeding and sleeping habits, and feeling tense to low energy levels (Hasin et al., 2018). The patient rates his depression scale from 1 to 10 at 8. He asserts that he does not sleep well, he never enjoys hunting as he used to in the past and at the same time, he does not enjoy eating but only does it so that he can stay alive.
Bipolar 1 Disorder
Bipolar disorder would be the second differential diagnosis based on the patient’s history which indicates he was in the past diagnosed with the condition. The DSM-5 criterion for the diagnosis of bipolar 1 requires that a patient at least show one manic episode that lasts a week (American Psychiatric Association, 2013). More so, the patient should show three or four of the following symptoms: agitation, decreased sleep, pressured speech, racing thoughts, and heightened activity. The patient’s subject information indicates that he gets angry and moody at times, has tons of energy, and ends up staying on at night cleaning his garage.
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) refers to a condition that makes people feel anxious and restless. The DSM-5 diagnostic criterion for GAD requires the patient to present with symptoms like excessive worry and anxiety, fatigue, restlessness, difficulty sleeping, impaired concentration, and increased muscle aches as well as soreness (Lani et al., 2019). Based on the patient’s history and appearance during the telehealth interview, he has impaired concentration, seems restless, and most importantly rates his anxiety levels at 8 on a scale of 1 to 10.
Reflections:
In a similar patient evaluation, what I would do differently before the interview would be to ensure that the patient is calm and therefore would engage him in some relaxation exercises such as deep and regulated breathing to reduce tension. The exercises would make him more alert and attentive during the interview process.
According to HealthyPeople 2030, the social determinant of health that would apply in this particular patient case would be social and community context. This social determinant of health emphasizes the need for people to maintain healthy relationships and interactions with family and community members since the relations have a major impact on their overall well-being and health outcomes (Office of Disease Prevention and Health Promotion, 2022). The patient’s inability to control his emotions is likely to affect his marriage and relationship with his children. it would therefore be vital for the patient to seek psychiatric care to help him deal with his psychiatric issues.
Based on the patient’s history and case, one health promotion activity that I would do would be the provision of patient education regarding the importance of complying with medication. The patient’s history indicates that the patient was on depression medication though he stopped taking it. Improper discontinued of medication could result in a relapse of the symptoms which communicates the need for the patient to be sensitized to the need to comply with medication as prescribed. The patient should only discontinue the treatment plan upon assessment and recommendation by the therapist in charge.
Case Formulation and Treatment Plan:
Based on the patient’s case study, the most appropriate treatment modality that would be best for the patient would include a combination of both medication and psychotherapy. The patient should be put on antipsychotic medication to help deal with the psychiatric symptoms such as the depressive symptoms, anxiety symptoms, poor appetite, and agitation among others. The psychotherapy modality that would be appropriate for this patient’s case would be cognitive behavioral therapy. Cognitive-behavioral therapy entails distorting the maladaptive thoughts in a patient which could result in distorted thoughts, perceptions, and attitudes (Hirsch et al., 2019). The therapy enables an individual to take control of his perceptions and circumstances resulting in better life experiences.
The patient would need to visit the clinic or make a follow-up appointment after four weeks for an assessment of the effectiveness of the medications and therapy in alleviating the symptoms. The patient would need to be sensitized about the need for adherence to medication to lower the chances of relapse of symptoms as well as an increase in the burden of disease.
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.
Iani, L., Quinto, R. M., Lauriola, M., Crosta, M. L., & Pozzi, G. (2019). Psychological well-being and distress in patients with generalized anxiety disorder: The roles of positive and negative functioning. PloS one, 14(11), e0225646.
Office of Disease Prevention and Health Promotion,. (2022). Social and Community Context – Healthy People 2030 | health.gov. Health.gov. Retrieved 25 June 2022, from https://health.gov/healthypeople/objectives-and-data/browse-objectives/social-and-community-context.
Hirsch, C. R., Beale, S., Grey, N., & Liness, S. (2019). Approaching cognitive behavior therapy for generalized anxiety disorder from a cognitive process perspective. Frontiers in psychiatry, 10, 796.