Comprehensive Psychiatric Evaluation Template

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): S. Hicks

HPI: 26, Male VS- 136/72, 98.6, 18, 100 %. No pain

Past Psychiatric History:

General Statement: The client presents with an altered mood and affect, pacing back and forth in the office and refusing to answer questions when asked directly. He can talk about himself if prompted but continues to say "I don't know" when asked about his current symptoms or medical history. The client says he went through some traumatic events recently. He has experienced problems sleeping since the accident (August 2016) but cannot recall precisely how long ago it occurred because of his racing thoughts; however, he believes it may have been as far back as two months ago because of his sleep issues started then.

CAREGIVERS (if applicable):   None at this time?

Hospitalizations:   None at this time?

Medication trials:   Suboxone and Klonop

Past psychiatric history: The client recently underwent hospitalization for a suicide attempt and has a dependency on alcohol. He attempted to overdose on his prescription medication, Klonopin. He states that he has no history of suicide attempts or ideation until now. He also states that he has not had any major depression or bipolar episodes in the past but has anxiety and panic attacks. The client also states that he has been prescribed Lexapro and Zoloft in the past for anxiety, but they did not work well for him.

Substance Current Use and History: Oxycodone

Family Psychiatric/Substance Use History: No history of any mental illness in the family.

Psychosocial History: The client was a police officer but was terminated due to excessive time off. He also has a CODAR that he has been unable to follow up with as it is still open; this is an old case, so he might need to reopen it to get his PDMP number (Reiff et al., 2020).

Medical History:

Patient seems to be experiencing only minor distress. He crosses his legs while sitting on a chair with his arms tightly crossed over his chest. He appears apprehensive but not fearful. His affect is flat, and his speech is slowed. The patient has difficulty answering questions because he repeats the questions back to me before answering them. The patient says that he feels like he could have died from the accident. He says that he sometimes feels like people are talking about him when they are not but does not hear voices or see things that others do not see. The patient says he has no thoughts of harming himself or others now. The patient has been feeling depressed lately but denies having any suicidal thoughts or plans of harming himself at this time. His judgment and other cognitive functions like memory and concentration ability seem intact. The patient reports having racing thoughts, poor concentration/focus, and insomnia.

ROS:

● GENERAL: No physical findings of note. Vitals are within normal limits, BP 110/70, HR 70, RR 18, O2 sat 98% on room air. The client appears well-nourished and hydrated. Skin color is pale, with no lesions or rashes.

● HEENT: Eyes appear normal without swelling or discharge. Pupils react appropriately to light and accommodation (4mm). The nasal mucosa is moist. There is no crusting or drainage noted.

● SKIN: There are no rashes noted on the skin surface at this time

● CARDIOVASCULAR: Heart sounds are regular without murmurs or gallops heard bilaterally with a 1st ICS count of 2/6 with an apical S3 gallop heard at the apex on expiration

● RESPIRATORY: No pain, no wheezing, no cough

● GASTROINTESTINAL: Nausea, but no vomiting

● GENITOURINARY: The client is sexually active and has no complaints of pain or burning during urination.

● NEUROLOGICAL: The client has difficulty concentrating, but no other neurological complaints were noted during the interview. The client also has some racing thoughts, which were noted during the interview (Lisa et al.,2019).

● MUSCULOSKELETAL: The client appears to have normal muscle strength and tone during this assessment.

● HEMATOLOGIC: The client has no known bleeding issues or bruises.

● LYMPHATICS: CBC revealed WBC count of 18, Hgb at 100% (baseline), platelets at 100% (baseline).  No lymphadenopathy or splenomegaly was noted on physical examination.

● ENDOCRINOLOGIC: No abnormalities ies noted on the physical exam.

Physical exam: S=26 m=136/72 Ht=5’8 Wt=170 BP=98/60 RR=18 O2 Sat=100%

Diagnostic results:

The following are possible diagnoses:

1) Anxiety disorder; Generalized anxiety disorder (GAD)

2) Substance-related & addictive disorder; Alcohol abuse, drug abuse, opioid dependence, or misuse.

3) Trauma & stress-related disorder; PTSD.

In the patient's chart, he has been diagnosed with a “generalized anxiety disorder (GAD), panic disorder, social phobia, and OCD.” If a client presents with one of these disorders and other conditions such as an eating disorder or substance use disorder, then the diagnosis may be changed based on what is causing their symptoms. In this case, it appears that he also has an opioid dependence or misuse diagnosis, which would need to be added to his other diagnoses (De et al., 2020).

Assessment

The differential diagnosis for this client included PTSD, Anxiety Disorder, Substance-Related & Addictive Disorder, and Trauma & Stress-Related Disorder. I chose to treat the client for PTSD and Anxiety Disorder. The patient was diagnosed with an anxiety disorder because he did not have any symptoms associated with PTSD. Although he had flashbacks from the accident in August, he did not meet all of the criteria for PTSD as described in DSMV (Najavits et al., 2017). The patient was diagnosed with an anxiety disorder because he had many symptoms such as racing thoughts, poor concentration, insomnia, pacing all the time, cries, overwhelming feelings of sadness, guilt, and panic attacks.

Reflections:

There are several things I would do differently in the same patient assessment. First, I would have better understood the patient's history and how it relates to his current presentation. I would also have done a more thorough assessment of his mental status, including depression and PTSD symptoms and substance abuse history. Second, assess the client more thoroughly. I would take a complete history and do a mental status exam. I would also evaluate the patient in terms of his anxiety and depression symptoms and PTSD symptoms. I would also encourage this patient to participate in physical activity with his brother and sister-in-law, such as walking or running. I would also encourage him to eat healthy foods and avoid alcohol and drugs. If possible, I would like to get some information about the person's social determinants of health (SDOH) (Lyssenko et al.,2018). This includes their income level, education level, living situation, employment status, and access to food and housing. In this case, his SDOH is not very good based on his statements about homelessness and unemployment over time. Based on this information, I may want to refer him for additional services such as housing assistance or career counseling as needed.

As a future advanced nursing provider, one health promotion activity that we could do with this person is to get him involved in different programs so that he can meet new people who can help motivate him and keep him going when he feels like giving up on himself. Therefore, to improve his health disparities and inequities, I would educate him about managing his diabetes and blood pressure. I would also teach him how to use some stress management techniques like meditation or yoga. Lastly, I would help him find ways to cope with his anxiety disorder, such as relaxation techniques. 

References

De, R., Zabih, V., Kurdyak, P., Sutradhar, R., Nathan, P. C., McBride, M. L., & Gupta, S. (2020). A systematic review and meta-analysis of psychiatric disorders in adolescent and young adult-onset cancer survivors. Journal of adolescent and young adult oncology, 9(1), 12-22.

Lisa, P., Felicia, K., Laura, H., Daniela, K., Marlies, R., Stefanie, N., ... & Gabi, K. (2019). Associations between methamphetamine use, psychiatric comorbidities, and treatment outcome in two inpatient rehabilitation centers. Psychiatry Research, 280, 112505.\

Najavits, L. M., Hyman, S. M., Ruglass, L. M., Hien, D. A., & Read, J. P. (2017). Substance use disorder and trauma.

Lyssenko, L., Schmahl, C., Bockhacker, L., Vonderlin, R., Bohus, M., & Kleindienst, N. (2018). Dissociation in psychiatric disorders: a meta-analysis of studies using the dissociative experiences scale. American Journal of Psychiatry, 175(1), 37-46.

Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., Rodriguez, C. I., & Work Group on Biomarkers and Novel Treatments, a Division of the American Psychiatric Association Council of Research. (2020). Psychedelics and psychedelic-assisted psychotherapy. American Journal of Psychiatry, 177(5), 391-410.