Comprehensive Psychiatric Evaluation Discussion Paper

I picked 6 pages because the written is 5…and I would like a page to be what I will read my video presentation from. It cant exceed 8 minutes. I think 4 or 5 minutes is enough. My mom is sick, I dont have time to worry about tweaking anything. I just want to make the video reading from something. Also, I put a patient in the assignment instructions to use…you can add or make up any information that isn’t in the patient info I gave you. They dont check all the details like that with privacy laws. I uploaded the template and the exemplar template you have to use for the written part. If you need more pages for some reason within reason just do it and I would pay the difference if need be. But I think it’s enough. I dont know if any resources are needed, I couldnt find that info, but resources are fine.

Comprehensive Psychiatric Evaluation of a 30 Year-Old Female with Schizophrenia

CC (chief complaint): The client was brought with complainst of “becoming aggressive” on family members, “not sleeping”, and not eating. For instance, she had already assaulted her mother and knocked her tooth off. There was also the complaint of not complying with treatment or medication after discharge from the hospital. She is also addicted to substance use and her urine drug screen had just revealed that she was also smoking marijuana (positive for tetrahydrocannabinol).

HPI: The client is a 30 year-old Caucasian female presenting with aggression, insomnia, and loss of appetite. She has an extensive previous history of mental illness and the symptoms. The onset of the current symptoms was a few months ago after she refused to comply with treatment post discharge from the hospital six months ago. The location of the symptoms is in her head, her thought process and thought content. The duration of the symptoms is constant as gthey do not go away intermittently. Characteristically, the symptoms are persistent and recalcitrant. The aggression and insomnia are aggravated by attention given to her and relieved by fatigue. The timing of he symptoms is day and night. On a scale of 1-10 the sister rates her symptoms at 8/10.     Comprehensive Psychiatric Evaluation Discussion Paper

Past Psychiatric History:

• General Statement: This is a patient that has an extensive psychiatrics history and who has been in and out of the hospital for the same. She is non-compliant to treatment most of the time and appears to have poor judgment and insight.
• Caregivers (if applicable): Indeed this patien t requires caregivers as she needs someone to make sure that she takes her medications and also takes care of her activities of daily living or ADLs.
• Hospitalizations: She has been admitted to the hospital with mental health conditions many times before.
• Medication trials: She has not participated in any medication trials but she has been taking (albeit erratically) psychopharmacologic preparations.
• Psychotherapy or Previous Psychiatric Diagnosis: She has a previous psychiatric diagnosis and has also been to psychotherapy for her condition before.

Substance Current Use and History: The patient is an abuser of benzodiazepines and also smokes marijuana as revealed by the urine drug screen (UDS) done on her. This means she has been using these substances (has a history of use) and is also currently actively using them.   

Family Psychiatric/Substance Use History: The immediate family does not have a history of psychiatric illness. However, the maternal grandfather had a history of psychosis and was treated severally for the same. Two maternal uncles were also smokers of marijuana and used other substances as well. They were also in and out of hospital for the treatment of their condition. The paternal grandfather was a heavy alcohol drinker and actually died of liver cirrhosis. The sister denies any current substance or drug use by the members of the nuclear family.

Psychosocial History: The patient is clearly dysfunctional in terms of occupation, self care, and interpersonal relationships. She has two children but is not married and lives with her family of birth. The children live with her sister. She dropped out of school in the 11^th grade since she already started having mental health issues at that early age. At the present time, she is receiving every month a sum of $900 from the social services for her upkeep and that of the children. However, this is also where the source of funding for her addictions comes from.  

Medical History:

• Current Medications: This patient has been in and out of the hospital several times and is currently on the following medications that she erratically takes with noncompliance.

1. Clozapine (Clozaril) 50 mg by mouth every day.
2. Aripiprazole (Abilify) 25 mg by mouth every day (Stahl, 2017).

• Allergies: The patient has no known allergies to medications, food items, or environmental irritants.

• Reproductive Hx: She is ehetrosexual and fertile. She has a history of two pregnancies and has two surviving children with none dead or aborted/ miscarried. At present she does not have a boyfriend and has also never been married before.
  

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ROS:

• GENERAL: She denies fever, chills, fatigue, weight loss, or malaise.
• HEENT: She is negative for headaches, photohobia, tearing, otorrhea, tinnitus, rhinorrhea, sneezing, and sore throat.
• SKIN: She is negative for rashes, eczema, or itching.
• CARDIOVASCULAR: She denies any chest pains or chest discomfort as well as peripheral edema.
• RESPIRATORY: She is negative for dyspnea, wheezing, or coughing.
• GASTROINTESTINAL: She denies having any abnormalmbowel movements. She is negative for nausea, vomiting, or diarrhea.
• GENITOURINARY: She is negative for vagina discharge or lesions. She also denies usrinary retention, hesitancy, frequency of micturition, or the passing of cloudy urine.
• NEUROLOGICAL: She denies having paraesthesia, loss of bladder and bowel control, hemiparesis, or hemiplegia.
• MUSCULOSKELETAL: She denies having myalgia or arthralgia and states that she has a full range of motion around her joints.
• HEMATOLOGIC: She is negative for blood and clotting disorders. She also denies unusual bruises around her body.
• LYMPHATICS: Negative for lymphadenopathy or splenectomy.
• ENDOCRINOLOGIC: Denies hormonal therapy, polydipsia, pyphagia, heat intolerance, cold intolerance, or excessive diaphoresis.

Physical exam:

Vital signs: BP 120/70 regular cuff and sitting; P 65, regular; T 98.30°F; RR 15, non-labored; BMI 23.6 kg/m² (normal BMI).

General: The patient is alert and oriented in space and person. She is however disoriented in time and event. She is dressed inappropriately for the time of the day and year and looks clearly disheveled. Her speech is not goal-directec and appears disjointed and tangential with clear flight of ideas. All through the interview the client is fidgety and avoids to maintain eye contact. She sems far away and occasionally mentions things that are not even related to the psychiatric interview.

HEENT: The head is normocephalic and atraumatic. Both pupils are equal, spherical, and react to light and accommodation in the same way (PERRLA). Extra-ocular movement is unaffected (EOMI). Both tympanic membranes are not ruptured, and the external ear lobes are intact. On bilateral otoscopy, no fluid level is visible. The turbinates in the nose are not inflamed, and the septum is symmetrically situated medially. There is no sneezing or rhinorrhea. Her throat is neither erythematous but nor inflamed, and there is no exudate.

Neck: She does not have jugulo-venous distension or cervical lymphadenopathy.

Pulmonary: On auscultation there is no evidence of rhonchi, wheezing, crepitations, or rales.

Cardiovascular: HS1 and HS2 are audible on auscultation and normal in rate and rhythm. She does not have a gallop, a bruit, a rub, or a murmur.

Diagnostic results:

• Normal MRI and CT scans of the head
• A normal chest X-ray (AP)
• Normal full blood count and differentials with no anemia
• A positive and negative symptom scale (PANSS) score of 10 indicating moderate to severe schizophrenia (Leucht et al., 2019).

Assessment

Mental Status Examination (MSE)

The client is a Caucasian 30-year-old woman who is attentive and oriented to people and places but not to time or events. Her words are clear, yet they are not coherent or goal-oriented. Speech has lag and is monotonous. The volume is low, and the substance is sparse. She is inappropriately clothed for the time of day and the weather. She avoids eye contact, but she has no noticeable mannerisms, motions, or tics. The self-reported mood is “excellent,” yet the observed affect is dysphoric and out of sync with the self-reported mood. Perseverance and word salad are ancillary to the cognitive process. The substance of the thoughts reveals hallucinations, delusions, and reference notions. Both intuition and judgment are poor and compromised. However, there are no suicidal or homicidal thoughts. Her diagnosis is chizophrenia  whose DSM-5 diagnostic code is 295.90 (F20.9) (APA, 2013; Sadock et al., 2015).

Differential Diagnoses

1. Schizophrenia – 90 (F20.9)

Schizophrenia is the most likely primary diagnosis for the 30-year-old mother of two. Because the symptomatology presented meets the DSM-5 diagnostic criteria for that psychotic disorder, this is the case. For example, to diagnose schizophrenia, (A) at least two of the following symptoms must be present: delusions, catatonic behavior, hallucinations, negative symptoms such as avolition, and incoherence or disorientation of speech; (B) the level of functioning in at least one area (self-care, interpersonal relations, or work) must have decreased significantly as a result of the symptoms in (A); (C) the disturbance must have persisted for a total of six months; (D) Other psychotic disorders with psychotic features, such as schizoaffective disorder and bipolar disorder with psychotic features, must be ruled out; (E) the symptoms must not be due to pharmacotherapy or substance abuse; and (F) the patient must not have had an autism spectrum disorder or a communication disorder as a child (Sadock et al., 2015; APA, 2013). This diagnosis was reached after applying critical thinking to the patient’s symptoms in relation to the DSM-5 diagnostic criteria. She satisfies all of the criteria, indicating that she is most likely suffering from schizophrenia as a psychotic condition.

2. Substance-Induced Psychotic Disorder – 292.9 (F19.259)

This is the first possible differential diagnosis for this female client. This draws from the fact that her history of substance misuse, which includes cannabis is long. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5, the symptomatology of this diagnostic closely mimics that of schizophrenia in every regard. In fact, cannabis usage, especially during youth and early adulthood, is a proven risk factor for later-life psychosis (APA, 2013; Sadock et al., 2015).

3. Bipolar Disorder with Psychotic Features

Bipolar disorder is characterized by alternation between mania and depression. It is during the manic phase that the symptomatology of bipolar disorder with mood-congruent psychotic features mimics schizophrenia. There will be hallucinations, delusions, invulnerability, grandiosity, paranoia, and suspiciousness amngst others (APA, 2013; Sadock et al., 2015). This is a condition that must be ruled out too as it is a viable differential diagnosis for this 30 year-old mother of two.

Reflections

I performed this psychiatric interview following all the recommended evidence-based approaches as per Carlat (2017). Given another opportunity, I would still do the exact same things  did at ths time. The client was treated resectfully and informed cnsent was still sought despite a lack of insight and poor judgment. This respected autonomy as an ethical principle (Haswell, 2019). Confidentiality was also observed at all times. Given the dysfunction in the patient, the family was educated on how to help her and also cope with her condition. The emphasis was placed on adherence to treatment and medications. Caution was given to the family (represented by the sister) to look out for the doses taken by the patient to prevent overdose. A follow-up plan was drawn to see the patient after a period of four weeks.

Comprehensive Psychiatric Evaluation Discussion Paper