Comprehensive Psychiatric Evaluation Discussion Paper

Patient Information

Name: Kristen Watts Age: 29 years Sex: Female

Subjective

Chief Complaint (CC):

The patient described the reason for her office visit as worry, “I feel worried and dwell on it so much that I could spend hours thinking about all the possibilities. By the time I snap out of it, I have wasted so much time that I can no longer complete my daily activities satisfactorily.”

History of Present Illness (HPI):

K.W, a 29-year-old Caucasian female presenting for psychiatric evaluation for anxiety, has faced different mental health challenges since she was young. She believes that she is a result of incest and is currently undergoing a divorce, increasing her tendency to worry. Besides losing many daytime hours worrying, the patients struggle to sleep at night, resulting in fatigue and irritability. She seems willing to receive help. Comprehensive Psychiatric Evaluation Discussion Paper

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Review of Symptoms (ROS): The patient reports having depression and anxiety for the past 20 years, characterized by symptoms such as irritability, insomnia, feelings of guilt, anorexia, inability to concentrate, low energy levels, anhedonia, suicidal ideation and agitation (Christensen et al., 2020).

Anxiety: For the past 20 years, the patient has experienced anxiety symptoms, notably panic attacks, feeling on edge, concentration loss, insomnia, muscle stiffness and irritability (Bandelow et al., 2017).

Panic attack symptoms include hyperventilation, shortness of breath, dizziness, nausea, seizures, fainting and inability to control emotions.

Mania: The patient denies experiencing mania episodes

Psychosis/Schizophrenia: reports feeling highly paranoid and hallucinating, especially when extremely stressed.

Obsessions: The patient reports having a fear of germs and the compulsion to keep tabs.

Attention Deficit and Hyperactivity Disorder (ADHD): reports on and off ADHD symptoms accompanied with a BH screening of more than 30.

Post-Traumatic Stress Disorder: the patient reports presenting with hypervigilance, nightmares, avoidance and flashbacks for twenty years.

Borderline Personality Disorder: presents with a myriad of BPD symptoms, including unstable relationships and sense of self, the fear of abandonment, paranoia about people’s intention, drug abuse since teenagehood, binge eating and overspending. Comprehensive Psychiatric Evaluation Discussion Paper

Past Psychiatric History:

General Statement: The patient would visit a neuro doctor frequently in childhood and was first diagnosed with depression and anxiety in 2012 after abuse from the father.

Caregivers: seeing a therapist

Hospitalizations: The patient denies hospitalization, rehabilitation, or detox. She also denies suicide attempts: only wishing for death without coming up with a plan.

Medication Trials: The patient was previously on Ativan and later Xanax but discontinued because they are highly addictive. She also consumed Zoloft and Buspar but stopped because they made her go mad.

Psychotherapy: Despite presenting with mental illness symptoms for years, the patient has only started seeing a therapist recently.

Substance Use History: The patient vaporizes tobacco and is currently to stop using. She denies alcohol, caffeine, opiates, and illegal substance use. She has had a history of cannabis use since she was fifteen, but she has since stopped. The patient denies experiencing withdrawal symptoms.

Family History (FH): The patient reports that her mother abused drugs, but she appeared. None of her immediate family members presents with apparent signs of mental illness, but some extended family members on her maternal side have exhibited signs of schizophrenia.

Social History:

Although the patient’s mother abused drugs, the patient achieved all developmental milestones on time. However, she experienced lung collapse as a child. The patient was raised by both parents and claims that they abused her; they would give her chocolate milk and Benadryl to abuse her. Comprehensive Psychiatric Evaluation Discussion Paper

The patient currently lives in an extend-stay hotel with her 2.5-year-old son after separating from her husband while undergoing a divorce. Her highest level of education is a high school diploma, and she works as an exotic dancer. The patient denies any legal issues.

Medical History: Reports having seizures during panic attacks, physical, emotional and sexual trauma from abusive parents and head injuries.

Allergies: Penicillin, vancomycin and their analogues, as well as rubber and latex. Comprehensive Psychiatric Evaluation Discussion Paper

Current Medications:

1. For anxiety, the patient is on a 25 mg BID dosage of hydroxyzine (ATARAX) administered orally. The pharmacist dispensed 60 tablets refilled once.
2. For insomnia, the patient takes 1 50mg tablet of Quetiapine (Seroquel) every night. The pharmacist dispensed 60 tablets refilled once.

Reproductive Health: The patient identifies as heterosexual. Th current method of contraception is tubal ligation and is not sexually active.

Review of Systems:

Constitutional: Denies weight loss, chills and fever

HEENT: Denies hearing, vision, and mouth or throat problems

Cardiovascular: Denies angina or dizziness

Respiratory: Denies wheezing or apnea

Neuro: Reports intermittent seizure episodes

Genitourinary: Denies current dysuria or urine hesitancy

Gastrointestinal: Denies heartburn, nausea or vomiting

Objective

Vital Signs:

Weight: 52.7 kg Temperature (Taken Orally): 36.8 °C Blood Pressure Readings from past three visits: 115/77 Pulse Readings from past three visits: 80 Comprehensive Psychiatric Evaluation Discussion Paper

Physical Examination:

The patient is fully developed and nourished with no apparent signs of distress. The patient has equal bilateral chest expansion and no respiratory distress. She can move all appendages with a full motion range. From observations of the patient’s movement, she has relatively normal muscle strength and tone. No tremors, tics, atrophy or abnormal movements were observed. The patient was observed to have a normal gait and station.

Mental Exam:

The patient’s appearance is presentable; she is casually dressed in age-appropriate attire, and her speech and behaviour are as expected. Her mood is scattered, and her affect is mood-congruent. Nevertheless, her thought process is coherent, logical, and goal-oriented and denies thought disturbance. She is aware of her person, place and time and denies any suicidal intent: she does not make plans to commit suicide. Further, she denies the intention to harm others. Her insight, judgement and impulsivity are appropriate, and she can remember recent and past events. Finally, her fund of knowledge is consistent with the level of education

Diagnostic Tests: Generalized Anxiety Disorder (GAD-7), Patient Health Questionnaire (PHQ-9), and laboratory tests.

Assessment

Diagnostic Test Results:

The patient scored 21 on the GAD-7 Test, stating that she felt on edge, unable to control worrying, and unable to relax, rest and sit still almost daily. She also felt irritable and fearful almost daily. She reported that the anxiety impaired her ability to work, be present for family life and cultivate relationships with others. Comprehensive Psychiatric Evaluation Discussion Paper

The laboratory results revealed no history of drug use or abuse.

Suicide Risk; low

Exacerbating factors: history of family abuse and mental illness

Relieving factors: Comprehensive clinical care, easy healthcare access, family and community support, and spirituality.

Differential Diagnosis:

1. Comorbid GAD (generalized anxiety disorder) and schizoaffective disorder, bipolar type (HCC)

The patient’s symptoms and mental health test results are consistent with this diagnosis. The patient scored highly on the GAD, confirming a positive diagnosis. In this case, the GAD is comorbid in schizoaffective disorder because the patient also presents with intermittent hallucinations, paranoia as well as depression, a mood disorder. According to Wy TJP and Saadabadi (2022), schizophrenia diagnosis among family members increases the genetic risk of developing the schizoaffective disorder, and vice versa, as is the case with this patient (Wy TJP & Saadabadi A. The patient has been fighting depression for the past 20 years, presenting with anhedonia, insomnia, and suicidal ideation, among other symptoms.

2. Schizophrenia

Schizoaffective disorder may be misdiagnosed as schizophrenia because the patient presents with paranoia and hallucination. However, the symptoms do not meet the criteria for a schizophrenia diagnosis because the patient does not present with at least two active phase symptoms, notably hallucinations, disorganized speech or behaviour or delusions (Loch, 2019). In this case, the patient only presents with hallucinations. Moreover, the active phase does not last more than a month as required for a schizophrenia diagnosis: the patient only experiences hallucinations when they feel stressed. Comprehensive Psychiatric Evaluation Discussion Paper

3. Panic Disorder

The patient presents with some panic disorder symptoms, notably seizures, nausea, fainting, dizziness, shortness of breath and hyperventilation, that may result in misdiagnosis. However, the symptoms do not meet the criteria for a panic disorder diagnosis because they are episodic and do not last a month as required for a positive diagnosis (Kim, 2019). Moreover, a positive panic disorder diagnosis may require observation of behavioural change, which is not evident in this case.

Reflection

The comprehensive psychiatric evaluation of this patient shows that childhood trauma influences mental health significantly. According to Torjesen (2019), childhood trauma doubles the risk of developing mental illness. Although the patient achieved all her developmental milestones, she could not get past the family history of abuse. Indeed, the people who were supposed to protect her took advantage of her innocence and now the patient is constantly afraid that people will hurt her. Nevertheless, it is encouraging that the patient is willing to seek help and rectify past wrongs. With medication and therapy, the patient may become healthy enough to nurture healthy relationships with others. Some health promotion activities that the patient can undertake include practising cognitive behavioural therapy, listening to and reciting affirmations, taking responsibility for her happiness and drawing healthy boundaries. Comprehensive Psychiatric Evaluation Discussion Paper

References

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow

Christensen, M. C., Wong, C. M. J., & Baune, B. T. (2020). Symptoms of major depressive disorder and their impact on psychosocial functioning in the different phases of the disease: do the perspectives of patients and healthcare providers differ?. Frontiers in Psychiatry, 11, 280. https://doi.org/10.3389/fpsyt.2020.00280

Kim Y. K. (2019). Panic Disorder: Current Research and Management Approaches. Psychiatry Investigation, 16(1), 1–3. https://doi.org/10.30773/pi.2019.01.08

Loch, A. A. (2019). Schizophrenia, not a psychotic disorder: Bleuler revisited. Frontiers in psychiatry, 10, 328. https://doi.org/10.3389/fpsyt.2019.00328

Torjesen, I. (2019). Childhood trauma doubles the risk of mental health conditions. BMJ. https://doi.org/10.1136/bmj.l854

Wy TJP & Saadabadi A. Schizoaffective Disorder. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541012/ Comprehensive Psychiatric Evaluation Discussion Paper

Assignment 2: Comprehensive Psychiatric
Evaluation and Patient Case Presentation
Photo Credit: Pexels
Comprehensive psychiatric evaluations are a way to reflect on your practicum
experiences and connect the experiences to the learning you gain from your weekly
Learning Resources. Comprehensive notes, such as the ones required in this
practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you
examined during the last 2 weeks, using the Comprehensive Psychiatric Evaluation
Template provided. You will then use this note to develop and record a case
presentation for this patient.
To Prepare
• Review this week’s Learning Resources and consider the insights they provide
about assessment and diagnosis. Also review the Kaltura Media Uploader resource
in the left-hand navigation of the classroom for help creating your self-recorded
Kaltura video.
• Select a patient that you examined during the last 2 weeks who presented with a
disorder other than the one present in your selected case for Week 5.
• 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 SafeAssign Comprehensive Psychiatric Evaluation Discussion Paper

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.
• Develop a video case presentation, based on your evaluation of this patient, 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).

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• 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? Comprehensive Psychiatric Evaluation Discussion Paper
• 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 Discussion Paper