: Comprehensive Psychiatric Evaluation And Patient Case Presentation Video Case Presentati, Essays (university) of Nursing

Download : Comprehensive Psychiatric Evaluation And Patient Case Presentation Video Case Presentati and more Essays (university) Nursing in PDF only on Docsity! Week #5: Comprehensive Psychiatric Evaluation And Patient Case Presentation Video Case Presentation College of Nursing-PMHNP, Walden University PRAC 6635: Psychopathology and Diagnostic Reasoning Dr. Suhad Sadik October 1, 2023 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Introduction: Mood dissrordes can a include a variety of mentl health dissorder such as depression, mood dysregulations among others. Although these diseases can affect people of any age, recognizing them in teenagers can be particularly difficult because of the imbalances in their symptoms and their inability to express their emotions. While the exact cause of mood disorders is yet unknown, an imbalance in brain chemicals is assumed to be its root. Stressful life experiences and genetic predisposition are other causes of mood disorders. Overall, mood disorders have a serious impact on a person's mental health. In this assignment I will be focusing on gathering information from the patient and creating a Subjective, Objective, Assessment and plan (SOAP) analysis documentation note for a male patient who has been identified as having a mood condition. While gathering all necessary information I will be creating a differential diagnosis, that will help create a treatment plan in the future. CC (chief complaint): “I stopped taking the prozac about two months ago and started having increased anxiety and depression, and just keep loosing my train of thoughts, they seem all over the place.” HPI: 32 year old male presented to the clinic for initial evaluation for sympotms of anxiety and depression which he has been struggling with since 2016. He is a self reported hx of anxiety and depression. Stated that symptoms have gotten worse in the past few years. “Symptoms of depression are on and off since 2016, but escalated to anxiety and anger in the last two years” When patient was asked of what happened in 2016 and what is causing his symptoms of anger and anxiety in the last two years, pt was reluctant to answer. Reported taking Prozac and Ativan for anxiety. Reported episodes of anger outbursts and anxiety after he stopped taking Prozac. Endorses often episodes of panic attacks. “I get easily frustrated when things don’t go my way, which causes my panic attacks.” Pt is currently unemployed due to recent ankle surgery. Surgery was 2 months ago and pt is currently bedridden for recovery. Pt expressed concerns of having difficulties focusing and processing thoughts, which are causing him more frustration. He demonstrated guarded behavior about his past or family hx of substance abuse and alcohol history. Reported anxiety 10/10 in social setting and 3/10 when he is at home. Depression 3/10 which is triggered by self disappointment. Denies SI/SH/AVH at this time. Past Psychiatric History:  General Statement: Pt has been struggling with depression since 2016, but has gotten worse in the past few years causing symptoms of anxiety and anger.  Caregivers (if applicable): No caregivers specified. Living with his father  Hospitalizations: Previously placed on 5150 in ED due to panic attacks.  Medication trials: Prozac and Ativan, no dosage provided “cant remember the dosage”  Psychotherapy or Previous Psychiatric Diagnosis: Depression and Anxiety. Substance Current Use and History: Reported drinking a lot, but stopped two years ago. Refused to disclose his past substance abuse use and hx. Family Psychiatric/Substance Use History: Refused to disclose any family psychiatric/substance use history. “I stay out of families life and any business.” Pt did mention that some family members struggle with anger problems. © 2022 Walden University Page 2 of 10 and constant feelings of anxiety and nervousness. These symptoms are very similar to those that are often seen in people with anxiety disease. It's important to note that anxiety disorder frequently occurs in conjunction with PTSD because anxiety symptoms are significant components of the diagnostic factors for PTSD. 2. Depression Unspecified: According to the DSM-5 guidelines, Depressive Disorder “Not Otherwise Specified” is a category in the DSM-5 that is used when the symptoms of depression do not meet the criteria for a specific depressive disorder. It is generally a diagnosis of exclusion. It is given when depression signs are present but do not fit the specific criteria for conditions like Major Depressive Disorder, Persistent Depressive Disorder (Dysthymia), or other defined depressive disorders (American Psychiatric Association, 2022). This diagnosis is usually given when a patient's symptoms are clinically important and troublesome but do not fit the exact criteria for any other depressive disorder. It is often used when not enough information is available to make a more accurate diagnosis diisorder of Depression, Unspecified can mean a wide range of depressive symptoms, such as sadness, loss of interest or pleasure in activities, changes in appetite or weight, trouble sleeping, fatigue, feelings of guilt or worthlessness, trouble focusing, and even thoughts of death or suicide (American Psychiatric Association, 2022). It's important to keep in mind that while this category gives a broad diagnosis for people with depressive symptoms, it's important for specialists to review diagnostic assessmet PHQ-9 self assessemt questionaire and maintaining a close watch on the patient to see if they develop a more specific depressive condition over time. 3. Irritablity and Anger: According to DSM-5 when a diagnosis cant be concluded and additional diagnostic exams are necessary, Irritabliliyt and Anger” symptoms can be considered as a potential indicator for various conditions. It allows the psychitraist to evaluate the patient systemically, considering medical history, family history, diagnostic questionnaire results in order to differentiat between other possible diagnosis, and formulate most accurate diagnosis pertaining to the patient (Di Tella et al., 2022). Irritability and anger can be indicative of many underlying mental health disorders or medical conditions. Mood disorders, such as major depressive disorder, bipolar disorder, and disruptive mood dysregulation disorder may contain these characteristics. Additionally, these symptoms may be linked to anxiety disorders, post-traumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder (ADHD), and personality disorders, among others (American Psychiatric Association, 2022). Primary symptoms of the individual may include prominent and persistent irritability and anger, which can have a significant impact on their daily functioning and quality of life. These symptoms may be distressing for the patient and those around the individual, requiring clinical intervention. Reflections: After reflecting on this case, I agree with the preceptor's evaluation and diagnostic impression of the patient. Patients main complaint of increased anxiety and depression after stopping Prozac, along with a history of anxiety and depression, points © 2022 Walden University Page 5 of 10 to an anxiety disorder and an unspecified depressive disorder. Some of the patient's other symptoms, like anger outbursts, panic attacks, and trouble focusing, are signs of mental and psychological distress, which supports the diagnosis that irritability and anger could be symptoms of an underlying condition. The patient's guardedness about drug use and family background makes it important to dig deeper and build trust in future clinical evaluations. This case shows how important it is to do a full review that looks at both clinical and social factors that affect health of the patient. The fact that the patient recently lost his job because of ankle surgery and is now bedridden shows how much socioeconomic issues affect mental health (U.S. Department of Health and Human Services, 2023). Also, the patient's reluctance to talk about his family background and his social isolation could be signs that his mental health is being affected by cultural, interpersonal or even post traumatic factors. Therefore, it is important to be sympathetic and treating each patient with care especially when discussing sensitive topics. Protecting patients autonomy and rights in any presentable case is at extreme importance (Muschalla et al., 2018). In the future, I would focus on getting to know my patients well so that they trust me and we can talk freely. I would also learn more about the patient's social support network and cultural past, since they could affect how the treatment is planned and how well the patient follows it. I would also make sure that the patient's diagnostic evaluation includes recommended tests and screenings, such as the GAD-7, PHQ-9, and MDQ and PC-PTSD-5, in order to get a more accurate diagnosis to figure out the best way to help them. Overall, this case shows how important it is to take a complete approach to assessing and caring for patients, taking into account not only clinical factors but also social and cultural factors. Conclussion: Mood disorders cause individuals to have a change in their emotional state. In the presented case, the 32-year-old male who presented to the clinic for an evaluation. After a comprehensive evaluation of the patient, he was diagnosed with anxiety dissorder unspecified, depression dissorder unspecified, irritability and anger. When the patient completes all the diagnostic assessment tools provided, it will be evident of what is the cause of patients symptoms and confirm current diagnosis. For the treatment pt was restarted on Prozac 10mg daily for 2 weeks, then increase Prozac to 20mg QD and start Propranolol HCL 10mg daily. Interpersonal therapy and anger management classes have been recoomeneded and placed for referall. As to my knowledge as PMHNP I wouldn’t do anything differently. The PMHNP provided a thorough evaluation of the patient and ordered proper diagnostic tools, medications and therapy. After 3 weeks for the follow up appointment patient diagnosis and treatment plan will be re- evaluated. © 2022 Walden University Page 6 of 10 References: American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders American Psychiatric Association. (2022). Depressive disorders. In Diagnostic and statistical manual of mental disordersLinks to an external site .  (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787.x04_Depressive_Disorders American Psychiatric Association. (2022). Trauma- and stressor-related disorders.. In Diagnostic and statistical manual of mental disordersLinks to an external © 2022 Walden University Page 7 of 10