NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Mental health disorders pose various threats to populations and can significantly affect their quality of life. They can be precipitated by environmental changes such as trauma or other life experiences. These disorders can be managed through extensive patient evaluation for accurate diagnosis and to determine their underlying causes and help them accordingly.

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

The DSM V criteria are vital the accurate diagnosis, elimination of differentials, and patient management. Assessment and evaluation also help determine any factors contributing to the problem and allow the healthcare provider to manage it. This paper analyzes the psychiatric health of a patient going through much stress due to her husband’s drinking and evaluates differential diagnoses for the patient.

CC (chief complaint): “Going through a lot of stress and having really bad anxiety because of my husband’s drinking.”

HPI: A 40-year-old female came to the hospital. She complains of sadness, loss of interest in her hobbies, increased weight due to stress eating, problems initiating and remaining asleep, lack of energy, inattentiveness, guilt, frequent crying, frustration, and irrational fear regarding her children’s husband, work, and children’s. The symptoms have increased over the last few years.

She believes in her ability to handle the problems and has never sought medical or psychiatric help single-handedly until recently, when these symptoms overpowered her. The major source of stress is her husband, who was diagnosed with bipolar disorder 12 years ago. They have been married for 11 years.

The diagnosis led him to change jobs and miss work frequently, worsening her husband’s stress and resulting in heavy drinking. The husband is currently undergoing an intensive outpatient program which has helped him escape heavy drinking, which the client is happy about.

Past Psychiatric History:

  • General Statement: No history of a diagnosed psychiatric illness; it is her first psychiatric visit
  • Caregivers (if applicable): N/A
  • Hospitalizations: Denies previous hospitalizations
  • Medication trials: Denies history of medication trials
  • Psychotherapy or Previous Psychiatric Diagnosis: Denies past diagnosis of mental health disorders

Substance Current Use and History: Denies any current or past substance use.

Family Psychiatric/Substance Use History: The client denies any familial diagnosis of psychiatric illnesses. The client’s husband had an alcohol drinking problem that recently stooped after IOP and the client’s request. The client is happy about that and is now stressed due to her husband’s absence from work.

Psychosocial History: Has one sibling, grew up in Media, studied in Philadelphia, and lives in Media. Her first job was at QVC and in anthropology. She currently works in transportation project development, where she has worked for fifteen years. She reports dissatisfaction with the job because it is not her dream job, but she copes because it has good benefits, is flexible, and her income is stable.

The patient and her husband have been married for 11 years, siring twins, currently five years old, and will begin preschool this fall. Her parents and in-laws live nearby and form a strong social support system for her and her family.

Medical History:

  • Current Medications: None
  • Allergies: NKFD
  • Reproductive Hx: Sexually oriented to the opposite gender, married, has two five-year-old twin boys. Denies current or hx of STDs

ROS:

  • GENERAL: The patient report some unconfirmed weight gain due to stress eating, weakness, and fatigue most of the time. She denies fever or chills
  • HEENT: Head: Denies any injuries, headaches, or hair loss. Eyes: Denies pain, drainage, or visual changes. Ears: Denies pain, drainage, or hearing loss. Throat: Denies pain swallowing, dry through, or voice changes
  • SKIN: Denies itchy skin, dryness, rashes, lesions, or discoloration
  • CARDIOVASCULAR: Denies any chest pain, pressure, palpitations, or edema
  • RESPIRATORY: Denies coughing, congestion, or SOB
  • GASTROINTESTINAL: Patient reports increased appetite and subsequent stress eating. The patient denies diarrhea, constipation, vomiting, or nausea.
  • GENITOURINARY: Denies hx of STDs or UTIS, burning on urination, hesitancy, urgency, order, or urine coloration. She denies any changes in bowel movement.
  • NEUROLOGICAL: Patient denies dizziness, headache, tingling sensations, or loss of sensations in the extremities
  • MUSCULOSKELETAL: Patient denies joint, muscle, or back pain or stiffness and reports retained ability to perform activities of daily living.
  • HEMATOLOGIC: Denies easy bruising or uncontrollable bleeding
  • LYMPHATICS: Denies history of splenectomy, enlarged lymph nodes
  • ENDOCRINOLOGIC: Denies heat or cold intolerance, excess thirst, or excess urination

Physical exam: BP: 135/82, P: 76, T: 98F, RR:18, Pain: N/A

Diagnostic results: N/A

Assessment

Adjustment disorder is a short-term condition arising from difficulty managing sudden stressful life changes such as work-related issues, losing loved ones, and marriage and relationship issues, which lead to impairment (Kalauskas & Quero, 2020). The patient expresses her concerns which are her husband’s heavy drinking (which subsided recently after her request and beginning IOP) and frequent absence from work.

Symptoms of the condition include anhedonia, anxiety, insomnia, headache, anger, loss or increased appetite, and suicidal thoughts (American Psychiatric Association, 2022). The patient’s presentation meets the DSM V diagnostic criteria for Chronic Adjustment disorder with mixed depression and anxiety due to the symptoms of the depressed mood and persistence for over six months.

Kazlauskas and Quero (2020) note that a classic case of adjustment disorder is COVID-19 which has affected families’ integrity, people, lost jobs, and fear for individuals’ health, leading to increased global adjustment disorder prevalence. Adjustment disorder occurs in men and women of all ages, and treatment is brief to help realign the patient’s ability to cope with life stresses (Sadock et al., 2015).

Treatment entails psychotherapy and medications. Medications can either be antidepressants or anti-anxiety medications, depending on the patient’s presenting symptoms. Treatment response is higher when psychotherapy is used alongside medications than individual treatment.

Mental Status Examination: The patient is alert and oriented to time, place, and person. She is pleasant, cooperative, and has normal speech. The patient has a depressed mood and appears goal-directed but mildly distracted. The patient has full insight into the condition and seeks help to manage her excessive worries.

The patient’s judgment is intact, and she denies any suicidal ideations or behavior. She identifies ineffective coping mechanisms because she does not seek help but believes in her ability to handle her problems. The patient reports stress eating and increased appetite.

Differential Diagnoses:

  1. Generalized Anxiety Disorder

GAD is characterized by fear and worries without any obvious reason or specific course. The patient cannot identify a course for irrational fear. According to DSM V criteria, GAD is diagnosed when the patient has fear, nervousness, restlessness, poor concentration, irritability, muscle tension, insomnia, or worry regularly and severe in some days, without a specific course, for more than six months (American Psychiatric Association, 2022; Ströhle et al., 2018).

The patient presents with a majority of these symptoms, such as poor concentration, depression, and depressive symptoms, and her fears are directed to a specific course; her husband’s diagnosis, drinking problem, and frequent absence from work., thus ruling out the diagnosis.

  1. Major Depressive Disorder

Environmental stressors related to family and work can precipitate the disorder, although in most cases, the condition is idiopathic. Patients with major depressive disorder from environmental factors have ineffective coping mechanisms resulting in depression.

The patient is going through stressful events, and the diagnosis is possible for this patient. MDD is a severe mood disorder that can markedly affect the quality of life and performance of the patient’s daily living activities. A diagnosis of MDD is confirmed when at least five symptoms, such as consistent low mood, hopelessness, loss of appetite, insomnia, worthlessness, self-guilt, suicidal thoughts, inattentiveness, restlessness, psychomotor retardation, and anhedonia, last for more than two weeks (American Psychiatric Association, 2022).

The patient reports normal functioning at home and workplace and is only stressed by her husband’s situation. Kennedy (2020) also notes that the DSM V criteria for MDD diagnosis require that these symptoms must be affecting the patient’s daily functioning at work and social life, which has not been met for this patient, thus ruling out the diagnosis.

  1. Bipolar II Disorder

Bipolar II Disorder is a mood disorder that presents with oscillating cycles of hypomania and major depression symptoms. Thus, a diagnosis of major depression and a hypomania episode is necessary for the diagnosis of the disease, according to the DSM V.

For this patient, she has no presentations of mania, ruling out the condition. For this client coming to the clinic for the first time, it is important to delay the diagnosis and initiate symptomatic management for at least six months to allow time for monitoring and evaluation to ensure accurate diagnosis and management of the patient.

Reflections: Comprehensive Psychiatric Assessment allows the care provider to gather extensive patient information to inform their diagnosis and management. The patient’s assessment was patient-focused, emphasizing recovery and quality of life. An extensive review of the patient’s history and current presentations increased the possibility of accurate diagnosis and subsequent management.

The assessment also follows evidence-based guidelines hence its reliability. From the patient’s presentation and history, I agree with the adjustment disorder assessment. Careful analysis of the symptoms and their interrelatedness with the preceptor improved my understanding and enhanced my ability to pay attention to patient presentation details. I have also appreciated the importance of understanding how the conditions present due to the major similarities and differences in psychiatric disorders.

The comprehensive psychiatric assessment has also helped me appreciate the DSM V in diagnosing mental health illnesses and their management. Differential diagnosis help ensure the diagnosis selected is the most appropriate for the patient, prevents misdaignsiosi, and prevents delayed treatment, which causes increased patient deterioration. When managing mental illness patients, maintaining ethical standards such as respect for autonomy and confidentiality are also important considerations in developing a working relationship that leads to effective management (Sadocks et al., 2015).

References

Also Read: Factors that Influence the Development of Psychopathology NRNP 6635