NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Week 7: Comprehensive psychiatric evaluations
College of Nursing-PMHNP, Walden University
PRAC 6635: Psychopathology and Diagnostic Reasoning
Dr. Kieth Brown
TILMAN I’m terrible. Alright. I look terrible, I feel terr
Mrs. L.T., Gender: female Age: 32 years old, Race: Black
CC (chief complaint): “I have problem sleeping and has no appetite”
HPI: Mrs. L.T., a 32 year old Black lady present for evaluation due to her husband’s concern about recent changes in her behavior. Patient started to experience changes in mood and behavior after she had her first kid two months ago. She cries a lot and yells at every little thing. Patient complains about her body shape, her inability to go out and meet with friend and do other things that makes her happy. She states, “I look terrible, I feel terrible, my body is bloated, I have lines on my face, bags, I look disgusting, I want to run, but I don’t get out much, stuck at home with the kid, I haven’t seen my friends in forever, I can’t go out anymore.”
Past Psychiatric History:
· General Statement: For the first time, this patient’s mental state and growth are being observed.
· Caregivers (if applicable): none
· Hospitalizations: No prior hospitalizations, detoxes, or residential therapy.
· Medication trials: there are no previous medication trial.
· Psychotherapy or Previous Psychiatric Diagnosis: No sessions of psychotherapy or psychiatric diagnoses
Substance Current Use and History: No history of Legal or illicit drug misuse
Family Psychiatric/Substance Use History: Brother was addicted to methamphetamines and took his own life through GSW. Uncle was an opioid addict, but she denied using drugs or alcohol.
Patient recently had her first child two months ago. Currently married; stay at home mother after working in community library for 5 years. Grew up with her mother after her parents divorced when she was 16; has two sisters in Troy, Alabama. Completed education through bachelor’s level, majoring in English Literature. Prior to having her baby, patient enjoys writing and could write for hours at night. No previous suicidal gestures.
· Current Medications: Trandate 100mg twice daily for treatment of hypertension, admits to missing doses due to forgetting.
· Allergies: PCN
· Reproductive Hx: Patient is married with one child but says that she currently has no sex drive.
· GENERAL: she has gained weight and feel bloated with lines on her face.
HEENT: Head: the patient denies having ever been injured in the head. Eye: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat, or difficulty swallowing.
· SKIN: Skin is not smooth, has pimples and lines that are associated with the recent childbirth.
· CARDIOVASCULAR: Refutes experiencing tachycardia or chest pains. No chest pressure or chest discomfort, no palpitation or edema.
· RESPIRATORY: Denies shortness of breath and cough.
· NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. No previous suicidal gestures, currently seems to have a distorted thinking pattern and cites suicidal thought.
· MUSCULOSKELETAL: the patient refutes experiencing joint pains
· HEMATOLOGIC: the patient says that she has never experienced anemia or hemorrhage.
· GENITOURINARY: No burning on urination, urgency, hesitancy, or odor.
Physical exam: T- 98.6 P- 88 R 18 154/92 Ht 5’1 Wt 230lbs
Diagnostic results: No diagnostic test performed.
Mental Status Examination:
Ms. F. B., a 28-year-old African American lady who looks her stated age, neatly groomed and clean. she is cooperative with examiner with no evidence of any abnormal motor activity. She was able to maintain adequate eye contact. Her speech is clear, coherent, spontaneous, appropriate with normal rate, volume, and tone. Her mood is crying/tearful, and her affect dysphoric. Her thought process is coherent, and her thought content is unremarkable. No evidence of hallucination. Cognitively, she is alert and oriented to person, place, time, situation, and time. She has no apparent deficits to attention, concentration, memory, and abstract thinking is concrete. Her insight and judgment is fair. There is risk of harm to self, and others.
An adjustment disorder is an emotional or behavioral reaction to a stressful event or change in a person’s life that hinders social performance and functioning. It occurs during a period of adaptation to an important existential change or a stressful event, whether traumatic or not, and results in a depressive reaction or disturbance of emotions and behavior for a long or short time (Tonerio et al., 2019). The patient is in a postpartum period and postpartum period, in turn, involves the emotional and physical changes of pregnancy that tend to intensify and generate profound social, psychological, and physical alterations in women, which increases their risk of suffering psychiatric disorders (Tonerio et al., 2019). There is need to early and appropriate assessment of postpartum women who report emotional disturbances as Childbirth can trigger AD, which may, consequently, harm the health of mothers and newborns and affect the relationship of postpartum women with the people around them. To be diagnosed with adjustment disorder, a person must exhibit emotional or behavioral symptoms related to an identified stressor. The stressor does not have to be ongoing Multifarious, or recurring. Individuals or whole families may be affected by the stressor (Bachem, & Casey, 2018).
Major Depressive Disorder
The DSM-5 defines MDD as the presence of five or more of the specified symptoms. A diagnosis of MDD may be made if five or more of the specified symptoms are present for two weeks, according to the DSM 5. Suicidal ideation can include symptoms such as a depressed mood (signs of hopelessness or sadness), loss of enjoyment, sleep disorders (insomnia and hypersomnia), psychomotor agitation and retardation, excessive or inappropriate guilt, and recurrent thoughts of death or suicide (Cooper, 2018). Hopelessness and helplessness are the primary emotions shown by this patient.
Generalized Anxiety Disorder
According to the DSM 5, GAD is characterized by symptoms including restlessness, exhaustion, irritability, and muscular tension, as well as an inability to manage one’s worrying regularly for at least six months (DeMartini, Patel, & Fancher, 2019). Research using the GAD-7 as a diagnostic tool found that symptoms including an inability to stay still or worrying about too many different things boosted a patient’s rating on the scale.
The interview with the client helped reveal important information essential in the diagnosis process. It is important to be conscious of cultural prejudices and identify and clarify the patient’s cultural biases. The patient should also consider mental health services’ efficacy and possible obstacles to treatment objectives. People may be afraid to seek help for mental health problems because of cultural misconceptions. Expanding on the patient’s upbringing, as well as their dependency on others, is essential. A better grasp of the patient’s life story can help you better understand how she views family and how to better meet her unique and therapeutic objectives.
The legal and ethical considerations that I would consider while handling the patient include maintaining the patient’s autonomy during the treatment process. This can be achieved by enlightening the patient about the different treatment processes that can be used in managing her case and their side effects so that she can participate in selecting the most appropriate method (Valient et al., 2019).
The health promotion exercises I recommend for the patient include adhering to the prescribed treatment regimen. This is significant because it will help eliminate the condition’s clinical symptoms and increase the patient’s functionality (Valiente et al., 2019).
Bachem, R., & Casey, P. (2018). Adjustment disorder: a diagnosis whose time has come. Journal of affective disorders, 227, 243-253.
Cooper, R. (2018). Diagnosing the diagnostic and statistical manual of mental disorders. Routledge.
DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine, 170(7), ITC49-ITC64.
McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., … & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841-1856.
Tenorio Ferreira, Q., Souza Vasconcelos de Lima, L., de Lima e. Silva, L. X., Ferreira Aquino,
D. M., & de Lima Castro, J. F. (2019). Adjustment disorder resulting from childbirth:
evaluation of signs and symptoms in postpartum women. Revista Eletronica de
Enfermagem, 21, 1–10. https://doi.org/10.5216/ree.v21.53876
Valiente, C., Espinosa, R., Trucharte, A., Nieto, J., & Martinez-Prado, L. (2019). The challenge of well-being and quality of life: A meta-analysis of psychological interventions in schizophrenia. Schizophrenia research, 208, 16-24.
ible. My body is bloated. I have lines on my face, bags. I look disgusting.
© 2021 Walden University Page 1 of 3