NRNP 6635 Week 9: Psychiatric Assessment Paper

NRNP 6635 Week 9: Psychiatric Assessment Paper

NRNP 6635 Week 9: Psychiatric Assessment Paper

Psychopathology and Diagnostic Reasoning

CC chief complaint): “The patient has suicidal ideation.”

HPI: The patient is a 32-year-old Hispanic male with a history of depression, anxiety, and substance use, and he was brought into the inpatient behavioral unit by the LAPD, presenting with suicidal ideation and danger to himself. From the reports, the patient had shown an intention of getting into a physical confrontation in the hope that he would get shot in the head to end his life. The patient indicated that he also got into a fight with his brother after he drank too much alcohol and also stormed out of his auntie’s house into the street. Having been outside in the cold weather for a long, the patient felt that he could pass out from the cold. Therefore, he approached police officers and informed them he wanted to kill himself so that through admission into the facility, he could get a warm place to stay. He indicated that he had feelings of low frustration tolerance, helplessness, lack of social support, and suicidal ideation to overdose on medications. He was considerably restless and anxious on admission.

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Past Psychiatric History:

• General Statement: The patient has a history of depression, anxiety, and substance use which has required psychiatric treatment
• Caregivers (if applicable): The patient has a girlfriend and an aunt who could be his caregivers
• Hospitalizations: No history of hospitalizations given
• Medication trials: No records of medication trials
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has previously been diagnosed with depression, anxiety, and substance abuse

Substance Current Use and History:

Family Psychiatric/Substance Use History: The is no significant family psychiatric or substance use history

Psychosocial History: the patient is currently thirty-two years. He was born and raised in California by both parents. Both parents are alive with no significant physical or mental health history. The patient has two other siblings, an elder brother, and a younger sister. He has a college education and was until recently working with a local insurance company. He currently has a girlfriend with whom they are expecting a daughter together.

Medical History:

• Current Medications: The patient is currently not using any medications
• Allergies: No known allergies

• Reproductive Hx: The patient is sexually active with one girlfriend. They are expecting a daughter together.

ROS:

• GENERAL: No weight loss, fever, chills, weakness, or fatigue.
• HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
• SKIN: No rash or itching.
• CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
• RESPIRATORY: No shortness of breath, cough, or sputum.
• GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
• GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
• NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
• MUSCULOSKELETAL: No muscle, or back pain, joint pain, or stiffness.
• HEMATOLOGIC: No anemia, bleeding, or bruising.
• LYMPHATICS: No enlarged nodes. No history of splenectomy.
• ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia

Physical exam:

Vital signs: Blood pressure 118/76 mmHg, Pulse rate 78, Temperature 98.0, Height 5’4, Weight 165 lbs

General: The patient looks healthy. However, he is restless and anxious.

HEENT: The head is atraumatic, pupils react normally to light, no eye or ear discharges, the neck is normal, no throat inflammation.

Neurological: The cranial nerves are intact. The patient is also alert and oriented.

Cardiovascular:  the S1 and S2 are both normal, and no murmurs were detected.

Musculoskeletal: There is no muscle or joint tenderness, no joint swelling, no stiffness, and no limitations in the range of motion.

          Respiratory: No chest pain noted. Normal breathing with no labored breathing noted

Gastrointestinal: no abdominal pain; the bowel sounds present

Diagnostic results: positive for alcohol abuse.

Assessment

Mental Status Examination:  The patient presented to the unit appropriately dressed and well-groomed. He is calm, cooperative, and pleasant on approach. He has a bright affect and an improved mood. The patient has coherent speech. He denies any homicidal or suicidal ideation and has no plan or intent reported. The patient is aware that his substance use is negatively impacting his life and believes he can achieve sobriety with the help of his supportive girlfriend. The patient has the right concentration levels.

Differential Diagnoses

 

1. Major depressive disorder: A major depressive disorder may present in episodes and may present with various symptoms. According to DSM-V, the patient with the condition may present with various symptoms including feelings of hopelessness, emptiness, sadness, frustration, irritability, and angry outbursts (Kennedy, 2022). Other symptoms include restlessness, agitation, anxiety, feelings of worthlessness, thoughts of death, suicidal thoughts, and suicide attempts. The patient was brought in exhibiting several of these symptoms, including suicidal thoughts and thoughts of dying. He also reported feelings of helplessness. Therefore is one of the possible diagnoses.
2. Generalized Anxiety Disorder: This is a condition that causes a change in an individual’s behavior and how they feel about other things. This condition presents with various symptoms such as restlessness, irritability, difficulty concentrating, a sense of fear or dread, and constantly feeling on edge (Crocq et al.,2022). The patient exhibited some of these symptoms, such as irritability and restlessness, which makes this a possible diagnosis.

• Alcohol abuse disorder: This is a disorder that results from excessive alcohol abuse, and the patient reaches a point where they cannot control drinking due to dependence (Castillo-Carniglia et al.,2019). The patient reports getting into a fight with his brother after drinking too much alcohol. Due to poor judgment after heavy drinking, the patient stormed out of his aunt’s house to live in the streets, where he experienced extreme cold.

Reflection

This case presented a chance for further learning regarding mental health assessment, presentation, and treatment. I agree with the preceptor’s assessment and diagnostic impression since they were based on the DSM-V criteria. One of the things I learned from this case is that mental illnesses can always recur even if an individual is undergoing psychiatric treatment (Davey & McGorry, 2019). In addition, I also learned that alcohol could enhance mental illnesses such as depression. One of the things I would do differently is getting more information about the individual’s behavior from where he is working and more information from the girlfriend to have more information that can be used to make a better decision. The ethical considerations include ensuring that the patient’s autonomy is upheld as well as privacy (Ellis, 2020). The patient also needs some education regarding adherence to medication as prescribed. Social determinants of health, in this case, include social support. The patient has indicated that he lacks social support at present, though he believes that his girlfriend can be supportive when he goes to live with her. The social support should therefore be improved to help the patient, especially regarding his alcohol addiction.

References

Castillo-Carniglia, A., Keyes, K. M., Hasin, D. S., & Cerdá, M. (2019). Psychiatric comorbidities in alcohol use disorder. The Lancet Psychiatry, 6(12), 1068-1080. https://doi.org/10.1016/S2215-0366(19)30222-6

Crocq, M. A. (2022). The history of generalized anxiety disorder as a diagnostic category. Dialogues In Clinical Neuroscience. https://doi.org/10.31887/DCNS.2017.19.2/macrocq

Davey, C. G., & McGorry, P. D. (2019). Early intervention for depression in young people: a blind spot in mental health care. The Lancet Psychiatry, 6(3), 267–272. https://doi.org/10.1016/S2215-0366(18)30292-X

Ellis, P. (2020). Understanding ethics for nursing students. Sage.

Kennedy, S. H. (2022). Core symptoms of major depressive disorder: relevance to diagnosis and treatment. Dialogues In Clinical Neuroscience. https://doi.org/10.31887/DCNS.2008.10.3/shkennedy

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COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 6 case presentations into this final presentation for the course.

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCE

TO PREPARE
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media resources in the Classroom Support Center (accessed via the Help button).
Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using Turn It In. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Then, based on your evaluation of this patient, develop a video case presentation that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
Ensure that you have the appropriate lighting and equipment to record the presentation
ASSIGNMENT
Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.

In your presentation:

Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:

Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
Reflection notes: 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.
COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 6 case presentations into this final presentation for the course.

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCE

TO PREPARE
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media resources in the Classroom Support Center (accessed via the Help button).
Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using Turn It In. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Then, based on your evaluation of this patient, develop a video case presentation that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
Ensure that you have the appropriate lighting and equipment to record the presentation
ASSIGNMENT
Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.

In your presentation:

Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:

Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
Reflection notes: 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.
https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x13_Sexual_Dysfunctions

https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x18_Personality_Disorders

https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x19_Paraphilic_Disorders

PATIENT TO BE PRESENTED

DISCHARGE SUMMARY

HISTORY OF PRESENT ILLNESS:

Patient is a 32-year-old Hispanic male with history of substance use, anxiety and depression requiring in patient psychiatric treatment presents with suicidal ideation brought in to BHU by LAPD on 5150 for danger to self. According to hold, patient intended to get into a physical altercation in hopes he would get “shot in the head” to end his life. The patient claimed to have gotten into a fight with his brother after drinking too much alcohol and stormed out of his aunt’s house to the street. The patient reported he was outside in the cold weather and felt as though he was going to pass out from cold. He said he approached the police offers and told them he wanted to kill himself so that he can be admitted to a facility so that he can have a warm place to stay. . He reported helplessness, low frustration tolerance, lack of social support and suicidal ideation to overdose on medications. The patient was overly anxious and restless on admission.

Upon evaluation today, patient is calm cooperative and pleasant on approach. Patient presents with bright affect and improved mood. He expresses optimism about the upcoming birth of his daughter and reports a good relationship with his girlfriend. He denies suicidal and homicidal ideation, no plan or intent reported at this time. He is aware of his condition and the role it played in the inciting event. He is also aware of how his substance use is negatively impacts his life and is confident he can work towards sobriety with the help of his supportive girlfriend. Patient is able to contract for safety at this time. Patient is evaluated to be stable and clear for discharge to live with his girlfriend. Reeducated patient on importance of medication compliance. Patient verbalized understanding and agreed to comply with treatment regimen. Social services and nursing staff notified to assist patient with outpatient follow-up care.