Comprehensive Psychiatric Evaluation

Tina Cherry

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Dr. Clark

April 21, 2022

Comprehensive Psychiatric Evaluation

Subjective

CC (Chief Complaint): Depression

HPI: 54-year-old white female. Individual reports depression has increased. “I been dealing with my boyfriend being in the nursing home. I have no desire to do anything. I just feel depressed and all I do is lay around crying.” Individual reports anxiety the same. She reports Seroquel helps with sleep and denies side effects from medications. Individual rates life 4/10 with 10 being the happiest. She denies SI/HI at this time.

Past Psychiatric History

General Information: The case is a 54-year-old female

Caregivers (If Applicable): The patient does not have a caregiver.

Hospitalizations: Inpatient psychiatric facility within the past 6 months

Medication Trials: No medical trials

Previous Psychiatric Diagnosis: Bipolar Disorder, Anxiety, and Depression

Substance Use and History: No history of substance abuse

Family History: Mother (deceased) cancer, mood disorder

Psychosocial History: Bipolar disorder, depression, and anxiety

Medical History: HTN/ COPD- Bronchitis/Emphysema/ Type II DM/ Hyperlipidemia

Current Medications:

Quetiapine 50 mg, Oxycarbazepine 300 mg, Fluticasone propionate 50 mcg, Loratadine 10 mg, Levothyroxine sodium 50 mcg, Montelukast sod 10 mg, Losartan potassium 50 mg, Novolog 100 units/ml vial; Diltiazem HCL ER coated BEA, VIT D2 1.25 mg (50,000 unit).

Allergies: The patient has no allergy, nor does she have any reaction to certain aspects such as seasonal changes, dust, or pollen.

Reproductive Hx: The patient began her menstrual periods at 15. The patient has no history of reproductive health complications.

Past Medical History: Bronchitis/Emphysema

ROS:

GENERAL: The patient is composed and well-presented. The patient’s speech is clear. The patient is depressed, and her melancholy interferes with her ability to function. However, during an examination and the chat, the patient is easily distracted (McCutcheon et al, 2020). The patient suffers from anxiety, insomnia, despondency, a sense of worthlessness, anxiousness, delusions, and hallucinations.

HEENT: The patient’s vision and hearing are both in good shape. There is no history of glaucoma or other eye disorders in this patient (Angst & Cassanoy, 2018). The hearing and sense of smell are in good working order. Furthermore, the patient’s dental health is satisfactory, and his throat is free of cancer or sore throat.

SKIN: The patient has no wounds, itches, or bruises.

CARDIOVASCULAR: The patient has no dyspnea, palpitations, or oedema problems.

RESPIRATORY: The patient has a history of bronchitis

GASTROINTESTINAL: The patient has no reflux, abnormal bowel sounds, or abdominal pains.

GENITOURINARY: The patient has had tubal ligation and vulvectomy in the past

HEMATOLOGIC: The patient has no blood disorder, and she has no history of cancer.

LYMPHATICS: The patient has no issues or challenges relating to pain or swelling of the lymph nodes.

ENDOCRINOLOGIC: The patient has not reported any issues of endocrinal challenges.

Objective

Physical Examination: Vitals are as follows: Height 5’11, Weight 247 lbs, BMI 34

Diagnostic Results: Blood and urine tests returned typical results, and the MRI and Ct scan also returned specific results.

Assessment

Mental Status Examination:

The patient is a 54-year-old white female with an age-appropriate look. The patient is aware and cooperative, and she is usually tidy, clean, and well-dressed. There are no abnormalities, and the patient always speaks clearly and coherently (Gordovez, 2020). The patient’s memory, focus, and insight are intact. However, the patient reports a lack of happiness daily over the past two weeks.

Differential Diagnosis:

Bipolar Disorder

Bipolar disorder is a mental condition where a person experiences some hypomanic disorders characterized by increased energy or irritability. They have symptoms alternating between feelings of lows and highs. People who experience bipolar disorder also experience depressive episodes where these people have low moods, and such people tend to isolate themselves from the public. The diagnostic criteria for the condition are the presence of hypomanic episodes. The hypomanic episodes are characterized mainly by inflated self-esteem. The main signs of bipolar disorder are depressive episodes, weight loss and changes in mood swings.

Depression

Depression is a mental health challenge where the individual usually has mental health challenges due to constantly thinking about a particular situation, which makes this person detached from the everyday world. People who suffer from depression tend to have suicidal or homicidal thoughts, which affect the. Some of the common symptoms of depression include changes in sleep patterns, overeating or eating and changes in mood swings. Additionally, people battling depression like staying alone most of the time. The primary diagnostic condition of depression is the changes in mood swings and the hallucinations that one might experience.

Reflections:

The final diagnosis is bipolar disorder. The patient has been treated for bipolar disorder in the past. The final diagnosis for the patient is bipolar disorder. The patient rates her happiness levels as 4 out of 10. The best treatment plan will be using suitable medication and counselling therapy (Carvallo et al, 2020). Non-pharmacological and pharmacological methods must be used to treat bipolar disorder. The pharmacologic treatment will be Fluticasone propionate 50 mg daily and Loratadine 2 mg, Levothyroxine sodium 2 tablets each daily. Cognitive theraphy will also be given to ensure that behavior is corrected. The patient will also be encouraged to adjust to her diet and avoid saturated fat, red meat and simple carbohydrates. Additionally, the patient should be educated on how to stick to the treatment, the possible side effects and how to manage these side effects.

References

Angst, J., & Cassano, G. (2018). The mood spectrum: improving the diagnosis of bipolar disorder. Bipolar disorders, 7, 4-12.

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66.

Gordovez, F. J. A., & McMahon, F. J. (2020). The genetics of bipolar disorder. Molecular psychiatry, 25(3), 544-559.