Comprehensive psychiatric Evaluation and patient case Presentation

Week 7: Comprehensive Psychiatric Evaluation and Patient Case Presentation

 

 

 

Esther Ruminjo

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Dr. Heidi Hollinger

January 15th , 2023

 

 

 

 

 

 

 

 

 

 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

 

When it comes to diagnosing and treating mental health illnesses, psychiatric evaluation is crucial. Through assessment includes assessing. This comprehensive psychiatric evaluation will examine the patient to be presented, the chief complaint, history of present illness, steps taken for assessing the conditions and symptoms, interventions and planning . ‘

CC (chief complaint): ‘ I just came from jail’

HPI: J.J is a 48 years old single white male who present to the office seeking help so that he does not go back to drugs. Patient reported he was incarcerated for the past 11 years for stealing, arson and drug related changes. Patient was released from jail recently and is currently living with his elderly parents. Patient is on probation for five years and currently has a life coach to help him cope. Patient reports he has been dealing with drugs and alcohol starting at a young age. He started smoking marijuana when he was 14 and started using cocaine, heroin and opiates at age 18. Patient reported he has been in and out of jail most of his life. His last incarceration being the longest. Patient reports he has been dealing with depression and anxiety since he was in high school. He reported he also dealt with racing thoughts, poor appetite, feeling overwhelmed and sweaty hands. He denies paranoia and AH/VH. Patient has history of suicidal ideation and attempted to hang himself when he was 16 years old. He denies any history of psych hospitalizations. He denies any current suicidal/ homicidal ideations.

Past Psychiatric History

  • General Statement: The patient has been under treatment for depression and anxiety disorders since he was in high school. He entered treatment for substance addiction.
  • Caregivers (if applicable): The caregivers are his elderly parents. 
  • Hospitalizations: Patient denies any history of psych hospitalizations.
  • Medication trials: Clonidine 0.2 mg po twice daily, olanzapine 7.5 mg po daily, escitalopram 10mg po daily, mirtazapine 30mg po  daily, pramipexole 0.125 mg daily and suboxone 8 mg daily.
  • Psychotherapy or Previous Psychiatric Diagnosis: Patient went for Behavioral psychotherapy 

Substance Current Use and History: Patient has past history of alcohol abuse, but is now sober. He used THC, Opiates, cocaine, heroin but he no longer does. He is currently treated with suboxone. He has not attempted any type of detox.

Family Psychiatric/Substance Use History: 

His family has a history of psychiatric related illnesses with two of his brother suffering from anxiety disorders and mood disorders. A sister with mental illness attempted suicidal by overdose. His father was also diagnosed with mood disorders including depression 

Psychosocial History: 

Patient was born and raised  in western Massachusetts by both parents in a family of  4 children, 3 brothers and one sister. Patient is 1 of the 4 children. Patient is currently living with his elderly parents after he was released from jail where he was incarcerated for 11 years. Patient has never been married but he has had failed relationships, he has 3 adults children and he is not in a good relation with 2 of the children. He just started mending the relationship with the youngest daughter who he has not seen for the last 11 year. Patient has been in and out of jail. His Education level was high school diploma and he secured an average GPA. He never went to college. He has in the past held part time jobs and was always fired because of substance and opiod abuse. Currently he is not employed, just released from jail. 

Legal history

Past incarceration- more than 3 years (drug related) , latest one was the longest for 11 years for drugs related and arson charges. Just got released and is in probation for the next 5 years.

Trauma history : No history of trauma

Violence:  Patient denies history of violence .

Medical History:

All systems reviewed and abnormalities documented 

No surgeries, no history of seizure, and no history of head trauma.

 

  • Current Medications
  • Clonidine 0.2 mg po twice daily, olanzapine 7.5 mg po daily, escitalopram 10mg po daily, mirtazapine 30mg po  daily, pramipexole 0.125 mg daily and suboxone 8 mg daily
  • Allergies: 
  •  
  • No known drug allergies . 
  • Reproductive Hx: 

ROS

  • GENERAL: Patient denies weight loss, fever, weakness, or fatigue 
  • HEENT: Eyes : denies eye pain or dryness photophobia. Ears, Nose, Throat: No tinnitus, hearing loss and no sneezing or congestion. 
  • SKIN: No dryness, rashes or itching .
  • CARDIOVASCULAR: No chest pain / discomfort or chest palpitation
  • RESPIRATORY: No difficulty breathing, or coughing.
  • GASTROINTESTINAL: No diarrhea, no constipation, and no appetite loss
  • GENITOURINARY: No burning sensation, no polyuria, no hesitancy 
  • NEUROLOGICAL: Denies headache, numbness or dizziness.
  • MUSCULOSKELETAL: No joint, muscle pain and no evidence of tremors
  • HEMATOLOGIC: No bleeding, no bruising, no anemia 
  • LYMPHATICS: No enlarged nodes or splenectomy 
  • ENDOCRINOLOGIC: No excessive urination, excessive thirst, no heat intolerance.

Physical exam: Patient currently doesn’t have a PCP,   in the process of establishing one. 

General: Normal general appearance, appropriate hygiene, friendly and cooperative attitude. Speech is normal rate, coherent , goal oriented, normal production. Well nourished. Height 5 feet 10 inches, weight : 212 pounds, BMI: 30.42, BSA : 2.18, sitting blood pressure 122/88 mmHg right upper extremity. Temperature 98.2 F, Heart rate 86, and respirations 22.

HEENT: Head atraumatic and normocephalic, pupils equal and reactive to light and accommodation. The tympanic membrane is intact- no redness, throat with no exudates. 

Neurologic: Cranial nerves are normal , symmetric reflexes and are intact . Patient is alert, oriented to person, place and time, able to focus on conversation, able to appropriately answer questions .

Psychiatric :No evidence of depression, anxiety or mania. No evidence of obsessive /compulsive symptoms, denies suicidal ideation and is able to contract for safety by agreeing to access services if needed. Affect is normal, full appropriate to mood. Thought have appropriate content with no evidence of delusional thinking or disorganization. No evidence of auditory or visual hallucinations. 

Diagnostic results:

Assessment

Mental Status Examination: 

Differential Diagnoses: 

Reflections:

 

 

 

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what am kindly requesting is you start from —

 

Diagnostics results 

Mental status Examination

Differential DX ( 3 )

Reflection

References .

Thanks 

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