A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay

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A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay

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.A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay.  Please include an introduction and conclusion Three differential diagnosis include reflections on what you would do differently using evidence based practice

Patient Initials: LM      Age: 30 Years     Race: African American (AA)      Gender: Male

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has a diagnostic category of mental disorders referred to as ‘Obsessive-Compulsive and Related Disorders’. This diagnostic category includes disorders such as obsessive-compulsive disorder (OCD), hair-pulling disorder or trichotillomania, body dysmorphic disorder, and substance/ medication-induced obsessive-compulsive disorder amongst others (Sadock et al., 20155; APA, 2013). Of these conditions, the characteristic presentation of OCD is obsessions, compulsions, or both. Obsessions are repeated, uncontrollable, and persistent stimuli in the form of images, thoughts and so on. These impulses are unwanted and intrude into the consciousness of the client, but they have no control over them. On the other hand, compulsions are behavioral acts or performances that are also repetitive and involuntary. The client feels compelled to perform these acts in a rigid predetermined way in response to some kind of obsession. Obsessive-compulsive disorder (OCD) is diagnosed using the DSM-5 under the code 300.3 (F42). To be diagnosed, particular criteria must be met. (A) The client must display obsessions, compulsions, or both; (B) the symptoms of obsession and/ or compulsion take up a lot of the patient’s time and impair their functioning in terms of social, occupational, and family duties and roles; (C) the two symptoms of obsession and compulsion as displayed by the client cannot be attributed to the effects of another medical condition or substance use; (D) the manifestations by the patient cannot be attributed to the presence of another mental disorder (APA, 2013). This paper is a comprehensive psychiatric evaluation of a 30 year-old African American man who presents with a primary diagnosis of OCD.

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SUBJECTIVE DATA:

CC (chief complaint): The patient was presented with a complaint of persistent, repetitive, and uncontrollable thoughts of an impending infection with the novel coronavirus for the last one month. The intrusive thoughts make him want to wash his hands several times in an hour to prevent this eventuality.

HPI: The patient is a 30 year-old African American male who presents with an obsession with coronavirus infection accompanied by a compulsion to wash hands too frequently. The obsession and compulsion are now causing him distress and preventing him from functioning at work, in his social life, and around his family. A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay. He denies any previous history of these symptoms before. The onset of the symptoms is reported to have been about 30 days ago. The obsession is a mental thought of getting infected with the Covid-19 and is therefore located in his mind. The duration of the thought of infection is just a few seconds but it is very frequent. The main characteristic of the thought of infection and compulsive handwashing is that they are unrelenting. The thoughts about Covid-19 infection are aggravated by watching and listening to news items about Covid-19 in the mass media. They are however relieved by engaging in some form of distracting activity such as sports. The obsession and compulsion are present especially during the day when the patient is awake. Patient LM rates the severity of the obsession and compulsion at 7/10.

Past Psychiatric History:

  • General Statement: This patient has not had a diagnosis of a mental condition since his childhood. He is in good general health and exercises frequently. Over the last few months, however, he has stopped going to the gym because he fears that he may get infected with the novel coronavirus. He does not have a significant psychiatric history in his family too.
  • Caregivers (if applicable): The patient can take care of himself and does not require having any caregivers.
  • Hospitalizations: he patient has only been hospitalized twice for non-psychiatric conditions. He has never been admitted with a psychiatric diagnosis.
  • Medication trials: He has never participated in any medication trials such as randomized blinded controlled trials (RCTs); be they psychiatric medications or not.
  • Psychotherapy or Previous Psychiatric Diagnosis: As stated above, patient LM has never been diagnosed with a mental health condition. For this reason, patient LM has never been treated with any psychotherapeutic interventions.

Substance Current Use and History:

He admits to a history of etoh for the last ten years. However, he denies engaging in binge drinking but only taking the etoh socially over the weekend with friends. He denies ever abusing prescription medications such as opiates, as well as substances such as cannabis. He also denies smoking either in the past or currently.

Family Psychiatric/Substance Use History:

His father was a social etoh consumer too. His mother who is still alive neither smokes nor drinks. He has two siblings one of whom is a smoker and the other who does not drink or smoke. No one in his family has ever abused opioid substances or cannabis.

Current Medications:

None

Allergies:

  1. NKDA
  2. No known food and food product allergies
  3. No known environmental allergies to irritants such as smoke, dust, or pollen.

Past Medical History (PMH):

  1. Community-acquired pneumonia in 2018
  2. Suspected rupture in peptic ulcer disease or PUD (2020)

Past Surgical History (PSH):

  1. ORIF left femur in 2012 after a motor vehicle accident. A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay.
  2. Laparoscopic abdominal surgery for suspected ruptured PUD in 2020.

Sexual/Reproductive History:

  1. He is heterosexual.
  2. He is married to one wife and has three children.

Personal/Social History:

He does not smoke and only occasionally takes etoh over the weekends when he is with friends. He states that he normally consumes a maximum of four beers on these occasions. He regularly takes meals that have enough fresh fruits and vegetables and does not like fatty foods. He has also been exercising regularly up to about three months ago when his fear started. He denies using marijuana, cocaine, heroin, methamphetamine, and prescription medications. His hobbies include meeting friends, motoring, and going for nature walks. His social circle of friends regularly gets together and drives to the countryside with their sports vehicles.

Immunization History:

The patient states that he completed his immunization schedule as a child. As an adult, he received his booster Tdp immunization in 2019. He has also lately received the influenza vaccine in 2020 and the pneumococcal vaccine in late 2019.

Significant Family History:

The father to patient LM died in 2019 from injuries sustained in a road accident. His mother is still alive and suffers from obesity and hyperlipidemia. His siblings are all in good health. There is no other significant family history that may explain his symptomatology as are all of his children.

Lifestyle:

Patient LM is a nursing faculty member at a local college and has lately been teaching only online classes because he is too afraid to venture outside the house. A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay.  He is financially stable and can afford to provide for his family of five. His income is also supplemented by that of his wife who is also a faculty member. They live in a well-to-do neighborhood with security and amenities. His social support network is good as his siblings and in-laws always check out on them.

Review of Systems (ROS):

General: Negative for malaise, fever, chills, fatigue, and recent loss of weight.

HEENT: Denies having headaches. Also denies photophobia, diplopia, or excessive tearing of the eyes. He denies tinnitus, nasal polyps, otorrhea, or hearing loss. Negative for hearing aids and eye glasses. Denies sneezing, rhinorrhea, and epistaxis. He has intact sense of smell. Last visited the otolaryngologist in September of 2019. He denies bleeding of the gums or the use of dental appliances. He last visited his dentist in March of 2020. There is no sore throat.

Neck: He denies swollen nodes or having a limitation in movement.

Breasts: Negative for exudate, lumps, and swellings.

Respiratory: Negative for difficulty in breathing, coughing, or hemoptysis.

Cardiovascular/Peripheral Vascular: Negative for chest tightness, palpitations, and chest pain. Also negative for intermittent claudication.

Gastrointestinal: Negative for nausea, vomiting, diarrhea, abdominal pain, melena, hematochezia, and hematemesis. The patient has regular bowel movements. Hs latest one was 12 hours to the clinic visit.  A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay.

Genitourinary: Negative for polyuria, polydipsia, urinary incontinence, and frequency of micturition. He is heterosexual, married, and has three children. He denies having ever suffered STIs.

Musculoskeletal: Negative for myalgia and arthralgia.

Psychiatric: Positive for recurrent, intrusive, and uncontrollable thoughts of getting infected by the novel coronavirus at any time. Apart from this obsession, also positive for compulsive handwashing aimed at mitigating the probable occurrence of the obsession with Covid-19 infection.   

Neurological:

Negative for unexplained syncope or dizziness in the past. Denies loss of consciousness or disturbances in gait. He also denies suffering seizures or unexplained falls. He does not have a loss of bladder or bowel control as well as paraesthesia in the extremities.

Skin: Negative for rashes and allergic dermatitis.

Hematologic: Negative for blood disorders and clotting disorders.

Endocrine: Negative for heat intolerance, excessive diaphoresis, and treatment with hormonal therapy.

Allergic/Immunologic: Negative for immunosuppression from any cause. He was last tested for the human immunodeficiency virus (HIV) in 2015 with a negative result.

OBJECTIVE DATA:

Physical Exam

Vital signs: BP 120/65 regular cuff and sitting; P 82, regular; T 98.5.0°F; RR 17, non-labored; BMI 24.9 kg/m2 (normal BMI).

General: A&O x 3, well-groomed for the weather and the time of the day. He looks anxious and apprehensive. His speech is clear and goal-directed. He does not have halitosis or body odors. His gait is not disturbed. He does not keep proper eye contact during the entire interview.

HEENT: Both of his pupils are equal in caliber, round and reactive to light and accommodation. The extra-ocular movements are intact. The tragus, the lobule, and the helix all are intact and show no signs of trauma bilaterally. A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay. Tympanic membranes are intact and there is no fluid level visible bilaterally. The nasal turbinates are not swollen and the septum is medially placed. There is no rhinorrhea or any exudate in the oronasopharynx.

Neck: On inspection the jugular vein is not distended and no cervical lymph nodes can be palpated.

Chest/Lungs: Clear lung fields on auscultation with no rales, rhonchi, crepitations, or wheezing.

Heart/Peripheral Vascular: S1 and S2 audible on auscultation and RRR. There is no gallop, bruit, rub, or murmurs.

ASSESSMENT:

Mental Status Examination (MSE)

The client is a 30 year-old African American male. He is awake, concious, alert and oriented to place, person, event, and time. He is dressed in appropriate attire for the time of the day and the weather and his speech is clear, goal-directed and coherent. The speech is however pressured in rate, the rhythm is articulated, the volume is loud, and the content fluent. He avoids direct eye contact for most of the interview and displays the notable tics of throat clearing and shoulder movements. His self-reported mood is “anxious”. Affect is euthymic and does not appear to be congruent with the self-reported mood. He denies any delusional or paranoid thoughts. He also denies having auditory or visual hallucinations. Insight is poor and explained by the fact that he was brought by his wife. Judgment is fair. He does not have suicidal or homicidal ideation. Diagnosis: Obsessive-Compulsive Disorder (OCD), 300.3 (F42).

Lab Tests and Results

  • WBC 9,600; RBC 4.55

Diagnostics:

  • Lab: CRP 3 mg/L; WBC 9,600
  • Radiology: A normal CXR

Differential Diagnoses

  1. Obsessive-Compulsive Disorder (OCD)

From the symptomatology of this patient, it is clear that he suffers from OCD. His symptoms of obsession and compulsion fit properly with the diagnostic criteria in the DSM-5 for OCD (Sadock et al., 2015; APA, 2013). The obsession in this case is with the possibility of contracting Covid-19, while the ensuing compulsion is handwashing that is too frequent to fall outside the boundaries of normality. A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay. The exact diagnostic criteria for OCD have been presented in the introduction to the paper. The critical thinking that went into this diagnosis took into account the specifics of the DSM-5 diagnostic criteria.

  1. Tic Disorder and Stereotyped Movements

This is a likely differential for OCD. However, the difference in diagnostic criteria is that tics and stereotyped movements are not as complex as compulsions. They are also not aimed at cancelling out obsessions. However, the distinction between a tic and a compulsion may be difficult. For this reason, OCD may co-occur with a Tic Disorder in the same patient (Bryan, 2017; Sadock et al., 2015; APA, 2013). Patient LM has been seen in the MSE to also display some tics. According to Stahl (2013), tics may be the result of specific neurobiological causes.

  1. Psychotic Disorders

Some patients presenting with OCD have poor insight (just like patient LM). They may even display delusions in addition to the usual OCD symptoms. For these reasons the diagnosis of OCD may be confused with that of a psychotic disorder such as schizophrenia (Sadock et al., 2015; APA, 2013). However, other psychotic symptoms need to be present for the diagnosis of a psychotic disorder to hold. Patient LM did not have delusions.

Reflection

Were I to do the comprehensive psychiatric evaluation of the patient again, I would not change the way I did the evaluation. According to Ball et al. (2019), Bickley (2017), and LeBlond et al. (2014); the process of history taking and physical examination of a patient (whether for medical, psychiatric, or surgical reasons) follows a strict laid down methodology. I made sure to follow this methodology to the letter when assessing patient LM. I also did a very thorough MSE to get to know his mental status. Respect for the bioethical principle of autonomy was maintained by getting informed consent for all procedures. A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay.  Beneficence was also assured by making the patient comfortable and ensuring they get the full benefits of the evaluation (Haswell, 2019). For prevention and promotion, the patent was advised to engage in activities that may distract him from the obsession. He also needs to get his social support network to discuss and disabuse him of the obsessive thoughts about the novel coronavirus. These discussions will help him with cognitive restructuring in the way cognitive behavioral therapy or CBT would do (Corey, 2017). He would need to have a person who would preferably be with him all the time.

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Conclusion

OCD is a mental health condition that is found in the DSM-5. It is characterized by obsessions that ten drive compulsions that appear abnormal to a normal person. The obsessions and the accompanying compulsions are repetitive, intrusive, ever-present, and difficult to get rid of. In this case of patient LM, he had poor insight and affect and mood that were incongruent. He however did not have any delusions or hallucinations. The diagnosis of OCD was conclusive as his symptomatology corresponded clearly with the diagnostic criteria for the condition in the DSM-5. A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay. 

References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

Bryan, D. (2017). OCD vs tics – What ‘s the difference? Anxiety House Brisbane. https://anxietyhouse.com.au/ocd-vs-tics-whats-the-difference/#:~:text=Tics%20are%20considered%20involuntary%20compulsions,that%20are%20rooted%20in%20anxiety

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th ed. Cengage Learning.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

LeBlond, R.F., Brown, D.D., & DeGowin, R.L. (2014). DeGowin’s diagnostic examination, 10th ed. McGraw Hill Medical.

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications, 4th ed. Cambridge University Press. A Comprehensive Psychiatric Evaluation of a Patient with Obsessive-Compulsive Disorder (OCD) Essay.