NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): ‘ I have been experiencing flashbacks and nightmares since I was involved in an accident eight months ago.’

HPI: Mrs. M is a 34-year-old client that came to the clinic for assessment for experiencing distressing flashbacks and nightmares about an accident she was involved in eight months ago. According to her, the accident claimed her husband and a friend, with her being the only survivor. She raised some complaints that she has been experiencing since then. They included recurrient distressing memories about the accident, intensive distress when she remembers it, and avoidance of any stimuli that resembles the event. The client noted that the symptoms started two months after the accident and have persisted since then. She denied suicidal thoughts, attempts, or plans.

ORDER A PLAGIARISM-FREE PAPER HERE ON;NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Past Psychiatric History: The patient denied any history of psychiatric conditions

• General Statement: ‘ I have been experiencing flashbacks and nightmares since I was involved in an accident eight months ago.’
• Caregivers (if applicable): none
• Hospitalizations: The client reported a history of admission last year when she was involved in the accident
• Medication trials: The client denied any history of medication trials
• Psychotherapy or Previous Psychiatric Diagnosis: The client denied any history of psychotherapy or previous psychiatric diagnosis

Substance Current Use and History: The client denied current or history of substance use or abuse

Family Psychiatric/Substance Use History: The client reported history depression (her mother) and alcohol use disorder (her father)

Psychosocial History: The client is widowed. She resigned from her work two months ago to give herself time to heal. She is a Christian. She considers religion a source of her social support. She lives alone in a rented apartment.

Medical History: The client reported a history of hospitalization last year following the accident

• Current Medications: The client currently uses acetaminophen for pain management
• Allergies: The client reported history of allergic reaction to penicillin. She reported that she develops difficulty in breathing whenever she uses the drug. She denied other allergic histories

• Reproductive Hx: Menarche was when she was 16 years. Her menstrual cycle is irregular, lasting five days. She is currently not sexually active. She is not using any contraceptive method. She denied history of pregnancy, pregnancy loss, dysuria, urgency, and frequency.

ROS:

• GENERAL: The patient appeared appropriately dressed for the occasion. There was no evidence of weight loss, fatigue, or fever.

• HEENT: The patient denies tinnitus, ear pain, discharge, and changes in hearing. She also denies head injury and headache. She denies blurred vision, dry eyes, eye pain, and eye redness. She denies nosebleeds, changes in sense of smell, and sinus pain. She denies dry mouth, changes in senses of taste, dental problems, difficulty in swallowing, and tongue problems. She denies sore throat, lymphadenopathy, swollen glands, and changes in voice.
• Neck: The patient denied neck pain or neck rigidity
• Breasts: She denied breast problems such as nipple changes and drainage or breast lumps
• Respiratory: She denied breathing problems such as wheezing, chest tightness, dyspnea, cough, and chest pain.
• Cardiovascular/Peripheral Vascular: She denied palpitations, edema, circulatory problems, vascular diseases, and irregular heartbeat
• Gastrointestinal: She denied nausea, vomiting, stomach pain, change in bowel movements, heartburn, indigestion, constipation, diarrhea, melena, and flatulence.
• Genitourinary: She denies dysuria, blood in urine, flank pain, incontinence, urinary tract or bladder infection, and abnormal vaginal discharge.
• Musculoskeletal: Denies muscle and joint pain, muscle weakness, joint swelling, backpain, and fractures
• Psychiatric: Denies mental health problems such as major depression, anxiety, substance abuse disorder, or obsessive compulsive disorder.  
• Neurological: Denies fainting, dizziness, vertigo, or lightheadedness.
• Skin: Denied easy bruising, edema, body sores, and rashes.
• Hematologic: Denies anemia and easy bruising or bleeding
• Endocrinologic: no lymphadenopathy, heat, or cold intolerance.

Physical exam: if applicable

Diagnostic results: Thyroid function tests were ordered to rule out hypothyroidism. The results were within normal range for thyroid hormones.

Assessment

Mental Status Examination: Mrs. M is dressed appropriately for weather and occasion. She is oriented to all facets. She demonstrates normal speech with no abnormal behaviors such as tremors and tics. Her thought process is intact. She denied illusions, delusions, and hallucinations. Her mood was flat with blunt affect. She denied suicidal thoughts, plans, or attempts.

Differential Diagnoses:

Mrs. M’s primary diagnosis is post-traumatic stress disorder. Post-traumatic stress disorder is a mental health disorder that individuals that have experienced or witnessed traumatic events develop. According to DMV, a patient is diagnosed with post-traumatic stress disorder if he or she presents with some symptoms. They include exposure to traumatic event either directly or indirectly by witnessing, learning from others, or being exposed repeatedly. Patients should also report symptoms that include recurrent distressing flashbacks, memories, or nightmares about the event. They should also demonstrate intense psychological distress when exposed to reminders and physical reactions. Patients should also have avoidance behaviors to the stimuli related to the trauma and negative alterations in cognition and mood, which affect their social and occupational functioning (Gelernter et al., 2019; Knefel et al., 2019; Price et al., 2019). Mrs. M has most of the above symptoms, making post-traumatic stress disorder the primary diagnosis.

One of Mrs. M’s secondary diagnoses is major depression. Major depression is a mental health disorder characterized by depressed mood, lack of interest in pleasure, hopelessness, guilt, and suicidal ideations, plans, or attempts. Patients also experience changes in sleep and appetite, weight, and their engagement in normal social and occupational roles (Bot et al., 2019). Mrs. M may have some of these symptoms but demonstrates avoidance behaviors and a history of traumatic event, which makes depression a least likely diagnosis. The other secondary diagnosis that may be considered is generalized anxiety disorder. Patients with generalized anxiety disorder experience symptoms such as excessive fear and worry that is often uncontrollable. The source of the concern may or may not be identifiable (Price et al., 2019). Generalized anxiety disorder is the least likely diagnosis because of the lack of excessive fear and worry by the patient.

Reflections: I agree with the preceptor’s diagnosis. The client’s symptoms align with those of post-traumatic stress disorder. One thing I will do differently should I experience a similar situation is linking the patient to the available social support groups for patients experiencing symptoms of depression and PTSD. I will research on the effect of factors such as level of education on the utilization of healthcare services in my community.

References

Bot, M., Brouwer, I. A., Roca, M., Kohls, E., Penninx, B. W. J. H., Watkins, E., van Grootheest, G., Cabout, M., Hegerl, U., Gili, M., Owens, M., Visser, M., & for the MooDFOOD Prevention Trial Investigators. (2019). Effect of Multinutrient Supplementation and Food-Related Behavioral Activation Therapy on Prevention of Major Depressive Disorder Among Overweight or Obese Adults With Subsyndromal Depressive Symptoms: The MooDFOOD Randomized Clinical Trial. JAMA, 321(9), 858–868. https://doi.org/10.1001/jama.2019.0556

Gelernter, J., Sun, N., Polimanti, R., Pietrzak, R., Levey, D. F., Bryois, J., Lu, Q., Hu, Y., Li, B., Radhakrishnan, K., Aslan, M., Cheung, K.-H., Li, Y., Rajeevan, N., Sayward, F., Harrington, K., Chen, Q., Cho, K., Pyarajan, S., … Stein, M. B. (2019). Genome-wide association study of post-traumatic stress disorder reexperiencing symptoms in >165,000 US veterans. Nature Neuroscience, 22(9), Article 9. https://doi.org/10.1038/s41593-019-0447-7

Knefel, M., Karatzias, T., Ben-Ezra, M., Cloitre, M., Lueger-Schuster, B., & Maercker, A. (2019). The replicability of ICD-11 complex post-traumatic stress disorder symptom networks in adults. The British Journal of Psychiatry, 214(6), 361–368. https://doi.org/10.1192/bjp.2018.286

Price, M., Legrand, A. C., Brier, Z. M. F., & Hébert-Dufresne, L. (2019). The symptoms at the center: Examining the comorbidity of posttraumatic stress disorder, generalized anxiety disorder, and depression with network analysis. Journal of Psychiatric Research, 109, 52–58. https://doi.org/10.1016/j.jpsychires.2018.11.016

BUY A CUSTOM-PAPER HERE ON;NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

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.

At least 5 recent references