Week 7: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders
College of Nursing-PMHNP, Walden University
NRNP-6635-15-Psychpathology Diagnoses Reasoning
Subjective:
CC (chief complaint): I have stomachache and I believe there is snake inside my stomach.
HPI: B.W is 33 years old Caucasian woman with a past psychiatric history and medical history of scoliosis. She was brought to emergency room by her friend due to her constant misuse of 911 and police was threatening to arrest her. She claims that some is been looking in her windows from across the street. She also stated that they are watching for her husband to return home so they can hurt him. She mentioned that she currently has stomachache and believes there is a snake inside ofher stomach that need to be removed. She has not eaten for the past two days due to it. During the assessment, she seens anxious, and paranoid. She refused to answer most of the questions that was asked because she doesn’t trust anyone. She had one psychiatric admission 2 years ago. No suicidal or self harm in the past, but had been physical aggressive to others. Sher denies any recent head injuries. She sleeps only one to two hours at a time and wakes up throughout the night. She refused her lab, and vitals. She also refused to answer questions whether there is memory or concentration problems
Past Psychiatric History:
- General Statement: Ptient was brought by her friend to the emergency room due to her recent paranpid and anxiety that some is watching her every move and her husband
- Caregivers (if applicable): None
- Hospitalizations: Psychitric hospitalization two years ago.
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: N/A
Substance Current Use and History: She drinks occasionally, denies drug use.
Family Psychiatric/Substance Use History: Her father is deceased, he had two previous inpatient psychiatric hospitalizations after bad drug experiences in the 1970s, for one week each time. He mother is deceased, she had depression. Her paternal grandmother was state hospitalized for several years.
Psychosocial History: She current lives in Atlanta, GA with her husband and has no children. She currently receives Social Security Disability Insurance. She has one sister that is ten years older than her. She was raised by both patent. She lost them two years ago, and that has been hard for her emotionally. She has a highschool diploma. No military service, No current legal issues
Medical History: Scoliosis
- Current Medications: None
- Allergies: haloperidol
- Reproductive Hx: No children
ROS:
- GENERAL: Recent weight loss. No fatigue, or weakness
- HEENT: Denies head trauma or head injuries, No vision discomfort, No ear loss, No rhinorrhea, sore throat or difficulty swallowing.
- RESPIRATORY: Denies shortness of breath, or cough
- PSYCHIATRIC: Reports anxiety, and no suicidal thoughts or attempts. Reports aggressiveness.
Objective:
Physical exam: She refused lab, and vitals
General: Patient is alert and oriented X4. She dressed appropriate.
HEENT: Normocephalic, Right and left PERRL, no hearing problem noted.
Respiratory: Chest wall and thoracic symmetrical when breathing.
Skin: Skin intact, no rashes noted
Psychiatric: Anxiety and paranoid noted.
Diagnostic results: Refused lab
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 (SCHIZOPHRENIA) to lowest priority. 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
Symptom Media. (Producer). (2018). Training title 134 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-134
Week 7: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders
College of Nursing-PMHNP, Walden University
NRNP-6635-15-Psychpathology Diagnoses Reasoning
Subjective:
CC (chief complaint): I have a stomach ache and I believe there is a snake inside my stomach.
HPI: B.W is 33 years old Caucasian woman with past psychiatric history and medical history of scoliosis. She was brought to the emergency room by her friend due to her constant misuse of 911 and police were threatening to arrest her. She claims that someone is been looking in her windows from across the street. She also stated that they are watching for her husband to return home so they can hurt him. She mentioned that she currently has a stomachache and believes there is a snake inside of her stomach that needs to be removed. She has not eaten for the past two days due to it. During the assessment, she seems anxious, and paranoid. She refused to answer most of the questions that were asked because she doesn’t trust anyone. She had one psychiatric admission 2 years ago. No suicidal or self-harm in the past, but had been physically aggressive to others. Sher denies any recent head injuries. She sleeps only one to two hours at a time and wakes up throughout the night. She refused her lab and vitals. She also refused to answer questions about whether there are memory or concentration problems.
Past Psychiatric History:
General Statement: The patient was brought by her friend to the emergency room due to her recent paranoid and anxiety that someone is watching her every move and her husband
Caregivers (if applicable): None
Hospitalizations: Psychiatric hospitalization two years ago.
Medication trials: None
Psychotherapy or Previous Psychiatric Diagnosis: N/A
Substance Current Use and History: She drinks occasionally, and denies drug use.
Family Psychiatric/Substance Use History: Her father is deceased, he had two previous inpatient psychiatric hospitalizations after bad drug experiences in the 1970s, for one week each time. Her mother is deceased, she had depression. Her paternal grandmother was state hospitalized for several years.
Psychosocial History: She currently lives in Atlanta, GA with her husband and has no children. She currently receives Social Security Disability Insurance. She has one sister that is ten years older than her. She was raised by both parents. She lost them two years ago, and that has been hard for her emotionally. She has a high school diploma. No military service, No current legal issues.
ROS:
- GENERAL: Recent weight loss. No fatigue, or weakness
- HEENT: Denies head trauma or head injuries, No vision discomfort, No ear loss, No rhinorrhea, sore throat or difficulty swallowing.
- RESPIRATORY: Denies shortness of breath, or cough
- PSYCHIATRIC: Reports anxiety, and no suicidal thoughts or attempts. Reports aggressiveness.
Objective:
Physical exam: She refused lab, and vitals
General: Patient is alert and oriented X4. She dressed appropriately.
HEENT: Normocephalic, Right and left PERRL, no hearing problem noted.
Respiratory: Chest wall and thoracic symmetrical when breathing.
Skin: Skin intact, no rashes noted
Psychiatric: Anxiety and paranoia noted.
Diagnostic results: Refused lab
Assessment:
Mental Status Examination:
The patient, a 33-year-old Caucasian woman appears her age. She is neatly groomed. She appears nervous, she is delusional and suspicious of her surroundings. Her thought process is incoherent, has poor concentration and she does not respond to the questions as she is supposed to. She appears to be in an irritable mood and delusional. There is evidence of a looseness of ideas. She does not smile at any moment during the interview. Her tone is not consistent.
Differential Diagnoses:
The differential diagnoses for the patient are schizophrenia, brief psychotic disorder, and delusional disorder.
Schizophrenia
Schizophrenia refers to a mental illness with a multifactorial etiology whose diverse variables interact with environmental factors . According to the Diagnostic Statistical Manual-5, for patients to be diagnosed with schizophrenia, they must present with two or more of the following symptoms, delusions, disorganized speech, hallucinations, negative symptoms, and grossly disorganized behavior (American Psychiatric Association, 2013). Schizophrenia is the priority diagnosis because the patient presents with a majority of the above symptoms. She is delusional, portrays disorganized speech by not answering questions as required, and has negative symptoms where she is paranoid about everyone around her.
Delusional disorder
Delusional disorder is a mental illness characterized by the presence of one or more delusions (Joseph & Siddiqui, 2019). The delusions are categorized into four categories namely, bizarre, non-bizarre, mood neutral, and mood-congruent. Non-bizarre delusions are can be possible but unlikely while the bizarre ones are strange. Mood congruent delusions concern false beliefs which align with a person’s mood. The patient presents with a delusion that someone is watching her.
Brief psychotic disorder
The brief psychotic disorder is a psychotic condition that is characterized by the onset of psychotic symptoms which should last for at least a day and not less than a month. The DMS-5 manual indicates that symptoms must include delusions, hallucinations, disorganized thinking and speech, confusion, disorientation, poor decision-making, problems with memory, and changes in one’s eating and sleeping patterns (Verinder & Baczynski, 2020).
Reflections:
If I were to see the patient again, based on her nervousness and anxiety levels, I would try to engage her in relaxation techniques such as deep and controlled breathing to enable her to relax, gain control of her thought and speech processes, and at the same time to have a constructive conversation.
I would carry out a health promotion activity that would be based on patient education on the need to comply with medical procedures such as taking vitals, laboratory testing, and other recommended screening tests for medical data collection. Similarly, I would caution the patient against alcohol use to minimize the risk of harm to herself and others.
Legal and Ethical Issues
Some of the ethical issues that would emanate from this case include her history of alcohol use, psychiatric hospitalization, and refusal to have vitals taken and diagnostic testing done. The above ethical issues would hinder her from receiving patient-centered care. Her reluctance to go through diagnostic testing hinders the clinicians to make accurate diagnoses thereby affecting therapeutic processes. Her history of psychiatric hospitalization indicates that she needs a patient-centered management plan that would result in an improvement in her well-being. Based on her delusions, it would be dangerous for her to take alcohol as it would continue to negatively distort her thoughts posing a risk not only to her but also to those around her.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Joseph, S. M., & Siddiqui, W. (2021). Delusional disorder. In StatPearls [Internet]. StatPearls Publishing.
Symptom Media. (Producer). (2018). Training title 134 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-134
Verinder, S., & Baczynski, C. (2020). Clarifying the onset of brief psychotic disorder at childbirth. Archives of women’s mental health, 23(2), 221-221.