PRAC 6645 WEEK 4 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1

Sample Answer

Subjective

CC (chief complaint)

” I have unpleasant symptoms.”

HPI

G.V is a forty-three-year-old white male patient who came to the clinic for a psychiatric checkup since he was told to seek help after exhibiting symptoms making him uncomfortable. The patient has been exhibiting periods of elevated moods, which also alternate with depressive mood periods. The elevated mood periods are characterized by excitement and, in some cases, delusions. Other symptoms experienced by the patient include being overactive, restless, and talking more than usual. He has also experienced problems falling asleep and easily gets distracted from sleep. Consequently, he experiences fatigue and feels tired during the day, which negatively affects his ability to complete his tasks. The patient also reports difficulty concentrating and forgetfulness.

Past Psychiatric History

• General Statement: The patient is visiting the facility having hopes of getting help from his unpleasant psychiatric symptoms.
• Caregivers (if applicable): the patient lives with the wife who is also the caregiver
• Hospitalizations: No history of previous hospitalizations
• Medication trials: No records of medication trials
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has a history of depression, and he has been managing the condition through medication use and psychotherapy

Substance Current Use and History

Family Psychiatric/Substance Use History

The patient’s family has no notable psychiatric history. He also denies any history of substance use

Psychosocial History

The patient was born and raised in M.N. The patient has three other siblings, an elder sister and two younger brothers. The patient is married, sexually active, and lives together with the wife. They have three children one adult boy and two teenage girls. The patient has a college degree and likes football The patient works in a local manufacturing company as a technical staff. He has no past legal issues, trauma or history of violence

Medical History

• Current Medications: The patient currently uses Wellbutrin to manage depression
• Allergies: No known allergies.

Reproductive Hx

The patient is married, sexually active. Denies having multiple partners.

Objective

• GENERAL: The patient has no distress and appears nourished and happy. However, he quickly gets tired of questions, and he feels he is under no obligation to answer them.
• HEENT: No headaches, no dizziness, no eye or ear pain, no nasal discharge, no blurred vision or vision changes, no reports of swallowing difficulty
• SKIN: No bruising, no lesions, no skin rash
• CARDIOVASCULAR: No chest pain, breath shortness, or chest tightness
• RESPIRATORY: No dyspnea, no cough, no reports of breathlessness
• GASTROINTESTINAL: No constipation, stomach upset and diarrhea
• GENITOURINARY: No frequent or urgent urination and no pain reported.
• NEUROLOGICAL: No numbness, no headache, no ataxia
• MUSCULOSKELETAL: No reports of muscle or joint pain.
• HEMATOLOGIC: No bruising or bleeding
• LYMPHATICS: No pain or swelling was reported
• ENDOCRINOLOGIC: No polydipsia or polyuria. No heat or cold intolerance, no sweating.

Vitals

• Temp – 98.6
• Pulse – 85
• Respiration – 18
• B/P – 116/80

Diagnostic results

Screening for alcohol and drug-using urine is negative.

CMP and CBC are both within normal ranges.

Assessment

Mental Status Examination

The patient is a forty-three-year-old white male patient. He is well-dressed and appropriately groomed. He is also alert and oriented in person, place, and time. His mood is excited, he appears restless, and he easily gets distracted. He has a pressured speech. He easily gets irritated when asked questions he perceives to be too much. The patient talks more than usual. He denies suicidal thoughts, ideation, or actions. He also denies hallucination. However, he has grandeur delusions. His judgment and thought process are both distorted. The patient exhibits distorted thoughts.

Differential Diagnoses

1. Bipolar disorder

Bipolar disorder is among the mood disorders known to negatively impact people’s lives. The patient has shown various symptoms, such as extreme mood swings where the patient experiences episodes of mania and depression. He has also experienced other symptoms, such as being overactive, restless, talking more than usual, problems falling asleep, and easily getting distracted from sleep. Consequently, he experiences fatigue and feels tired during the day, which negatively affects his ability to complete his tasks. Based on the DSM-5 criteria, bipolar disorder is the primary diagnosis (Rantala et al.,2021).

2. Generalized Anxiety Disorder

This is another potential condition based on some of the symptoms displayed by the patient. The patient has experienced fatigue and finds it difficult to concentrate. In addition, over the last few days, the patient has been showing symptoms such as sleep complications, finding it difficult to sleep, and easily getting distracted from sleep, making generalized anxiety disorder a potential diagnosis (DeMartini et al.,2019). However, manic symptoms are usually connected with bipolar disorder, making this condition less likely

3. Borderline Personality Disorder

Borderline Personality Disorder is another condition that the patient may be experiencing. A patient with this condition may present with emotional instability and impulsivity. Even though the patient is emotionally unstable, he has not shown any impulsive behavior, making this condition less likely (Bayes & Parker, 2020).

Reflections

A comprehensive assessment was important to help in the diagnosis and, consequently, a need to improve the patient’s condition. Therefore, an accurate diagnosis depends on various aspects such as the patient’s history of present illness, medical history, current medications, and mental health status assessment. It is important to note that all these are key to the formulation of a befitting treatment and management plan to help the patient recover from the illness or cope with the symptoms better. Given another chance to deal with the patient, there are things I would do differently; for instance, I would seek more information from the wife since such information can help in a more accurate diagnosis.

One social determinant of health that needs to be considered in this case is social support. It is important to inquire if the patient offers him the support he needs, and if not, appropriate arrangements should be made to ensure that the patient gets moral and social support to help him deal with the symptoms.

The use of medication in treating and managing patients requires a careful approach. For example, there is a need to educate the patient and family members on the importance of medication adherence and the dosage. In addition, it is important for them to know the adverse reactions which may need immediate attention from the medical team. As part of health promotion, the patient should be trained on how to improve sleeping habits to improve the quality of sleep and avoid other symptoms such as fatigue. The ethical principles should be considered in the plan formulation as well as medication prescription. Autonomy and non-maleficence should be upheld when prescribing psychotropic drugs as it will ensure patient safety (Hunt Grubbe et al.,2020).

Case Formulation and Treatment Plan

From the patient’s subjective information, objective information, and assessment, the primary diagnosis is bipolar disorder. Therefore, it is important that the patient gets an appropriate treatment plan that can help him deal with the symptoms for better outcomes. The patient is already using Wellbutrin to help in the treatment of depressive symptoms he is experiencing. As such, the patient should also integrate Lamictal, 25 mg BID, to help him stabilize his moods (Besag et al.,2021). In addition, the patient should continue with weekly sessions of psychotherapy to help with the symptoms. However, he needs to be educated on potential side effects, which may require immediate medical attention.

I confirm 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 course of learning.

Preceptor signature ________________________________________________________
Date ________________________

References

• Bayes, A. J., & Parker, G. B. (2020). Differentiating borderline personality disorder (BPD) from bipolar disorder diagnostic efficiency of DSM BPD criteria. Acta Psychiatrica Scandinavica, 141(2), 142-148. https //doi.org/10.1111/acps.13133
• Besag, F. M., Vasey, M. J., Sharma, A. N., & Lam, I. C. (2021). Efficacy and safety of lamotrigine in the treatment of bipolar disorder across the lifespan a systematic review. Therapeutic Advances in Psychopharmacology, 11, 20451253211045870. https //doi.org/10.1177/20451253211045870
• DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49-ITC64. https //doi.org/10.7326/AITC201904020
• Hunt-Grubbe, H. (2020). Ethical Issues Arising from the Prescription of Antipsychotic Medication in Clinical Forensic Settings. In Ethical Issues in Clinical Forensic Psychiatry (pp. 99-114). Springer, Cham. https //doi.org/10.1007/978-3-030-37301-6_6
• Rantala, M. J., Luoto, S., Borráz-León, J. I., & Krams, I. (2021). Bipolar disorder An evolutionary psychoneuroimmunological approach. Neuroscience & Biobehavioral Reviews, 122, 28-37. https //doi.org/10.1016/j.neubiorev.2020.12.031.