PRAC 6635:Psychpathology Diag Reason Practicum: Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation Case Study

PRAC 6635:Psychpathology Diag Reason Practicum: Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation Case Study

PRAC 6635:Psychpathology Diag Reason Practicum: Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation Case Study

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): “substance use”

HPI: L.P. is a 41-year-old Caucasian female who reported for psychiatric evaluation for opioid abuse. This is in response to her friends and family’s concerns about her long-term opioid usage. His family physician prescribed codeine for pain management for this patient six months ago. After completing her initial medication, the patient began looking for new ways to get the medicine and has been taking it without a correct dosing plan ever since. The woman believes that it helps to keep her calm and decrease the ‘continuous discomfort’. She has attempted to reduce her drug use but has been unsuccessful. Her continued usage of the substance has had a significant impact on her general social well-being as well as her performance at work. She frequently wishes to be alone and is continuously at odds with her spouse. The patient has been having persistent stomach discomfort, nausea, and vomiting.

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Past Psychiatric History:

• General Statement: The patient reports being unable to stop taking opioids following the previous prescription 6 months ago.
• Caregivers (if applicable): Lives with her husband
• Hospitalizations: None
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has no history of mental illness. There has been no prior therapy, detoxification, or rehabilitation.

Substance Current Use and History: The patient claims to have been consuming codeine for several months without a prescription from a physician. She was first prescribed codeine to manage her pain, but once her initial prescription expired, she began seeking other ways to obtain the medicine.

Family Psychiatric/Substance Use History: Denies having a family history of substance abuse, psychological disease, or suicide.

Psychosocial History: The patient has been married for the past 10 years with three children. She is presently concerned about her use of opioids which is affecting her marriage and work. She has a history of painful encounters but refuses to discuss them. She claims to sleep for roughly 6 hours per night. She admits to eating three meals every day.

Medical History: Reports a history of fibromyalgia.

 

• Current Medications: None prescribed
• Allergies: None

• Reproductive Hx: The patient reports regular menstruation and utilizes birth control pills.

ROS:

• GENERAL: Reports decreased energy levels. There will be no tiredness from a lack of sleep, lethargy, diarrhea, constipation, nausea, or vomiting.
• HEENT: Head: No trauma or headache. No visual abnormalities or double vision in the ears. There is no itching, tinnitus, or discharge in the eyes. No congestion, nasal bleeds, sinuses, inflammation, or stuffiness in the nose. No dental issues, bleeding gums, swallowing difficulty, or sore throat.
• SKIN: Pleasantly warm and moist, with no rashes, itching, or hives.
• CARDIOVASCULAR: There is no chest discomfort, palpitations, irregular heartbeat, or reduced exercise intolerance.
• RESPIRATORY: No difficulty breathing or dyspnea. Denies having a cough, congestion, or hemoptysis.
• GASTROINTESTINAL: No nausea or vomiting. Denies loose stools, constipation, hernia, abdominal discomfort, or bowel movement alterations.
• GENITOURINARY: Refuses to admit to having hesitancy, polyuria, dysuria, dribbling, or incontinence.
• NEUROLOGICAL: Reports occasional difficulty focusing. Denies headaches, balance issues, and numbness.
• MUSCULOSKELETAL: Full range of motion in all joints. There is no joint stiffness or discomfort.
• HEMATOLOGICAL: There is no bleeding, easy bruising, or other blood problem.
• LYMPHATICS: There has been no history of swollen lymph nodes.
• ENDOCRINOLOGIC: Refuses cold or heat intolerance, sweating, appetite changes, or hair loss.

Physical exam:

Vital signs: BP 136/87 HR 80 Temp 97.9 RR 20 Ht 5ft 7in. Wt. 125lbs B.M.I 19.58

Diagnostic results: A urine drug screen is required in this patient to establish the usage of opioids. Because the patient is also complaining of stomach discomfort, nausea, and vomiting, it is critical to do laboratory tests to rule out these symptoms. A full blood count to rule out leukocytosis and an erythrocyte sedimentation rate are both indicators of inflammation and underlying infection. Electrolyte values should also be checked to rule out any acidosis or alkalosis problems from recurrent vomiting. To rule out illnesses such as pancreatitis, liver enzyme levels, and pancreatic enzyme levels should be evaluated (Herscher et al., 2020).

Assessment

Mental Status Examination: The patient is a 41-year-old female well-dressed in age-appropriate clothing. During the assessment, she is courteous, calm, and helpful. During the interview and examination, there is no evidence of aberrant motor activity. The patient speaks well and coherently, and her voice is normal in volume and tone. Her cognitive process is in sync. This patient exhibits no looseness of association or flight of thoughts. She is in a euthymic state, with her mood and affects in sync. She experiences no auditory, tactile, or visual hallucinations or deletions, and she has no thoughts of harming herself or others. The patient is acutely aware of time, location, person, and circumstance. Her short-term, and long-term memories are all intact. Her focus is excellent. She has a strong understanding of her situation.

Differential Diagnoses:

1. Opioid use disorder (ICD-10 Code F11.288): Even after finishing her original prescription, the patient continues to consume opioids (Jones & McCance-Katz, 2019). She also reports unsuccessful attempts to limit her drug usage, which has had a significant impact on her social interactions with others and her general performance at work. As a result, this is the patient’s primary diagnosis.
2. Chronic pain disorder (ICD-10 Code G89.4): The patient mentions chronic pain and the need for codeine. Her general social life and career performance have suffered as a result (van Rijswijk et al., 2019). Opioid usage, on the other hand, appears to be the primary cause of most of her problems.
3. Avoidant personality disorder (ICD-10 Code F60.6): The patient has shown signs of social disengagement, both with close friends and at work. This began following the patient’s lengthy usage of codeine, which was identified as the primary cause of the patient’s current condition (Gosnell et al., 2020).

Reflections: If I were to do the interview over, I would make sure that at least one informant is present to confirm the patient’s history. A poor quality job is an important social health determinant in this patient. The patient works part-time, and it has been shown that unemployment and low-quality employment are key causes of mental health conditions (Herscher et al., 2020). Health promotion comprises encouraging the patient to participate in activities that reduce opioid usage while also ensuring that she is in an atmosphere where she may discuss any concerns she may have. Physical activity should be encouraged as a primary health promotion approach for the patient (Piske et al., 2020). Exercise helps to relieve long-term pain while reducing the patient’s reliance on medicines. Her educational history is an important factor to consider when informing the patient about her mental illness and available treatment options.

References

Gosnell, S. N., Crooks, K. E., Robinson, M., Oldham, J., Patriquin, M. A., Fowler, J. C., & Salas, R. (2020). Subcortical brain morphometry of avoidant personality disorder. Journal of Affective Disorders, 274, 1057–1061. https://doi.org/10.1016/j.jad.2020.05.127

Herscher, M., Fine, M., Navalurkar, R., Hirt, L., & Wang, L. (2020). Diagnosis and Management of Opioid Use Disorder in Hospitalized Patients. Medical Clinics of North America, 104(4), 695–708. https://doi.org/10.1016/j.mcna.2020.03.003

Jones, C. M., & McCance-Katz, E. F. (2019). Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and Alcohol Dependence, 197, 78–82. https://doi.org/10.1016/j.drugalcdep.2018.12.030

Piske, M., Zhou, H., Min, J. E., Hongdilokkul, N., Pearce, L. A., Homayra, F., Socias, M. E., McGowan, G., & Nosyk, B. (2020). The cascade of care for opioid use disorder: a retrospective study in British Columbia, Canada. Addiction, 115(8), 1482–1493. https://doi.org/10.1111/add.14947

van Rijswijk, S. M., van Beek, M. H. C. T., Schoof, G. M., Schene, A. H., Steegers, M., & Schellekens, A. F. (2019). Iatrogenic opioid use disorder, chronic pain, and psychiatric comorbidity: A systematic review. General Hospital Psychiatry, 59, 37–50. https://doi.org/10.1016/j.genhosppsych.2019.04.008

Hello Great Writer! Please see attached instructions, grading rubric, comprehensive psychiatric evaluation template you will use for this assignment and comprehensive psychiatric evaluation exemplar for you to follow and refer to in order to complete this assignment. Read instructions CAREFULLY and follow PRECISELY. I will present this this assignment via recording as well, so please utilize Turnit in drafts for originality report and please include ALL information needed to complete a thorough evaluation. Thank you. You will be creating a make-believe case study for a patient. Please make sure the the comprehensive assessment sounds REALISTIC! Please make sure the patient you create is exhibiting enough symptoms! Don’t make the case too easy. Symptoms and patient history and experiences presented must Match the primary diagnoses and secondary diagnoses. Make the patient’s signs and symptoms realistic. Please watch your turnit in.com percentage. Additionally, Please address each and every question in the reflections notes section. Thank you!