Week 4: Comprehensive Psychiatric Evaluation

Subjective:

CC (chief complaint): ‘As peaceful as I am, I troubled no one, however, those characters still pursue me.’

HPI: JD, 49 years old Caucasian man, was driven to the outpatient clinic by his uncle for psychiatric review and assessment. He lamented that a certain category of people had been a bother to his peaceful life. They talk to him and visualize them on his balcony, planning for his demise. Mr. JD is so affirmative and notes that those people are unaware that he knows all their planned motives against him. He further laments that the government is sponsoring those individuals to inflate his taxes.

The loudness of the said aliens from the government has since deprived him of his calm nights. For this, Mr. JD stays awake watching his favorite television shows, through which he is able to communicate to the army commander to keep him safe. He sometimes hides from those people by blindfolding his eyes. His uncle reports that JD’s symptoms have lasted for more than 14 months but cannot recall the very first time the symptoms were noted. In the past month, JD has been having minimal sleep time lasting between 4 and 6 hours daily because his “tormentors” do not sleep as well.

Past Psychiatric History: JD, having been on a few medications for his condition, has experienced various adverse outcomes using chlorpromazine and haloperidol. He has further developed gynecomastia from risperidone use. He, however, tolerates quetiapine very well. Nevertheless, Mr. JD has a strong conviction that the prescribed medications are poisons to wipe him out and is not ready to adhere to them. One of JD’s maternal aunts had schizophrenia but succumbed to cardiovascular complications more than 10 years ago. His father suffered from a generalized anxiety disorder. No one in his family has ever attempted suicide.

Substance Current Use and History: JD smokes on weekends and can smoke five packs a day with 21 bottles of beer every week. There is no history of hard drug use and abuse. He has never exhibited symptoms of withdrawal from the drugs he uses.

Family Psychiatric/Substance Use History: his mother had paranoid schizophrenia and his father had generalized anxiety disorder. Parents never had a history of substance use and abuse.

Psychosocial History: he has never been happier except after taking four bottles of beer in alcohol. He feels distant and detached from his colleagues and friends when sober. He worked as a receptionist at a local restaurant. His work output over the years has seen him move from the positions of management to manual roles.

Medical History:

Current Medications: Mr. JD takes amlodipine 5mg PO OD and hydrochlorothiazide 50mg PO OD for hypertension
Allergies: JD has no history of any known allergies, either to medication or food.

Reproductive Hx: Mr. JD was married for 7 years before his wife, whom he met with a daughter, divorced him on the grounds of desire for children, a fete JD failed to fulfill. He reports no history of sexually transmitted infections (STIs)

Objective:

Diagnostic results: a complete blood count showed normal parameters. He had normal thyroid function test results. He, however, had multiple cotton wool spots on his plain chest radiograph. Results for liver functionality are still being run in the lab.

Assessment:

Mental Status Examination: Mr. JD appears far much older than his age. His Glasgow Coma Scale is at 15/15. He is aware of his environment and those around him. He is wearing different colored socks. He has slurred speech with usual movements. He is easily distracted, does not trust everyone around him, and is unable to keep eye contact even for a minute, and also has both visual and auditory hallucinations alongside persecutory delusions. He has a flat mood and his affect corresponds to his mood. He is not aware that he is sick and that the medications will help him. He cannot recall his

wedding date.

Differential Diagnoses:

295.90 (F20.9) schizophrenia, multiple episodes, currently in an acute episode. This patient meets the diagnosis of schizophrenia according to the fifth edition of the diagnostic and statistical manual for mental disorders. He meets criteria A, B, C, D, and E (American Psychiatric Association, 2013). He has delusional thinking, hallucinations, disorganized speech, and avolition. These symptoms have been attributed to her current marital status and socioeconomic deterioration. His psychiatric history and mental state examination showed no mood and affective deficits. Therefore, schizoaffective and other mood disorders are ruled out. The temporal relationship between his alcohol use and current symptoms is negative and the latter are causative and not the outcome of the former. His childhood psychiatric history is nonremarkable and autism spectrum disorders are ruled out.
298.8 (F23) Brief psychotic disorder. The presence of delusions, hallucinations, and disorganized speech suggests a possibility of a brief psychotic disorder. According to the American Psychiatric Association (2013), a brief psychotic disorder can also present with these psychotic features. However, the duration of symptoms of this patient is more than six months, and he has been on treatment for schizophrenia for the past 2 years.
297.1 (F22) Delusional Disorder. The presence of delusions in this patient suggests the possibility of a delusional disorder. However, his presentation is predominantly hallucinatory and cognitive. The presence of the marked functional impairment makes delusional disorder less likely in this patient

Reflections: This patient’s case was classical schizophrenia because he met all the required criteria in DSM-5. Despite prior treatment with different antipsychotic medications, the patient did not respond well to treatment. At first, I thought that this was a case of treatment-resistant schizophrenia. Therefore, I prepared for clozapine treatment. On second thought, I decided to analyze this patient’s compliance and adherence to medications. The role of side effects of adherence was evident.

As part of the contribution to the healthy people-2030 objective MHMD-04, I believe that managing this patient to achieve remission will contribute to the desired increase in the proportion of people who receive treatment (U.S. Department of Health and Human Services, 2020). Incorporating the patient’s social background in making assessments was an ethical step that ensured I came up with a more appropriate diagnosis.

Case Formulation and Treatment Plan: the goal of pharmacotherapy is to reduce the disease sequelae and improve the quality of life. Per oral quetiapine 500mg every twenty-four hours (Vancampfort et al., 2021). The dose reduction of other medications is to be reviewed in the subsequent clinic visits, with monthly assessments. Patient psychoeducation and caretaker’s education n the need for adherence at the individual and family levels must be stressed (Stevović et al., 2022).

Family education on the course and prognosis of the disease and the possibility of relapses are explored and explained for better outcomes. Occupation therapy must also be sought to help Mr. JD gain his functionality and professional proficiency, which he lost and led to his downward promotion at work.

I confirm that the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek-approved clinical site during this quarter’s course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R)) (5th ed.). American Psychiatric Association Publishing.

Stevović, L. I., Repišti, S., Radojičić, T., Sartorius, N., Tomori, S., Džubur Kulenović, A., Popova, A., Kuzman, M. R., Vlachos, I. I., Statovci, S., Bandati, A., Novotni, A., Bajraktarov, S., Panfil, A.-L., Maric, N. P., Delić, M., & Jovanović, N. (2022). Non-pharmacological treatments for schizophrenia in Southeast Europe: An expert survey. The International Journal of Social Psychiatry, 68(5), 1141–1150. https://doi.org/10.1177/00207640211023072

U.S. Department of Health and Human Service. (2020). Schizophrenia: Overview. Health.gov. https://health.gov/healthypeople/tools-action/browse-evidence-based-resources/schizophrenia-overview

Vancampfort, D., Firth, J., Correll, C. U., Solmi, M., Siskind, D., De Hert, M., Carney, R., Koyanagi, A., Carvalho, A. F., Gaughran, F., & Stubbs, B. (2021). The impact of pharmacological and non-pharmacological interventions to improve physical health outcomes in people with schizophrenia: A meta-review of meta-analyses of randomized controlled trials. Focus (American Psychiatric Publishing), 19(1), 116–128. https://doi.org/10.1176/appi.focus.19103

Week 4 Instructions: Comprehensive Psychiatric Evaluation

Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide.

Include at least five scholarly resources to support your assessment and diagnostic reasoning.
Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
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.