Comprehensive Psychiatric Evaluation and Patient Case Study
Comprehensive Psychiatric Evaluation and Patient Case Study
Case Study
E. H., a 59-year-old male involuntarily committed to having auditory hallucinations, commanding him to kill himself and others. The patient reports hearing spirit. The patient has a history of crack cocaine abuse. The patient has a history of schizophrenia, hypothyroidism, and osteoarthritis. The patient stated that he is homeless, on disability, and unemployed. Psychiatric Evaluation and Patient The patient denied any family history of mental illness. The patient has a history of marijuana and crack cocaine use.
The patient had difficulty in conversation today. The patient complained about being tired, and not having enough sleep. The patient, in slow speech and tone, expresses having auditory hallucinations.
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The patient did not want to continue the conversation. The patient will be seen tomorrow morning.
During his mental status examination, the patient was cooperative with the examiner. He is casually groomed. There is no evidence of any abnormal motor activity. His speech is clear, coherent, and normal in volume and tone. His thought process is not goal-directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is anxious, and his affect is appropriate to his mood. He was neutral at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent memory and remote memory are intact. His concentration is good. His insight is poor.
TO PREPARE
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.
ASSIGNMENT
Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources.
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?
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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 Healthy People 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.
My Differential diagnosis
1-Schizophrenia
2-Schizoaffective disorder
3-Substance induce psychosis
My primary diagnosis will be Schizophrenia disorder.
Note: Please use DMS-5 criteria for each diagnostic.
