Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Paper
Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Paper
Subjective:
CC (chief complaint): “Psychiatric evaluation”
HPI: E. A is a 34-year-old female patient who reported to the clinic with a chief complaint of negative automated thinking, anxiety, and low self-esteem. She also reports symptoms of nightmares, feelings of loneliness, difficulty in making decisions, dizziness, career choice difficulty, inferiority feeling, difficult keeping her job, headache, palpitations, dizziness, fatigue, stiff shoulders/neck racing thoughts, panic attacks, bowel disturbance, and depression. The patient also reports difficulty relaxing with overall self-assessment perceived severity on a scale of 0 to 10, at 3 when she is most calm. She however reports that the nightmares have been more frequent like 4 times a week, while other symptoms occur almost daily.
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Past Psychiatric History:
General Statement: The patient reports a history of emotional abuse as she was bullied as a child. She also reports family discouragement from her aunts and father.
Caregivers (if applicable): The patient was raised by both her parents.
Hospitalizations: The patient reports no history of hospitalization.
Medication trials: The patient has previously used diazepam, letrozole, alprazolam, and cabergoline which were effective.
Psychotherapy or Previous Psychiatric Diagnosis: The patient reports a history of psychotherapeutic counseling last year for her current mental health issue.
Substance Current Use and History: The patient reports no history of substance use. She denies drinking alcohol or taking caffeine.
Family Psychiatric/Substance Use History: Father with a history of anxiety. Both her paternal and maternal grandmothers and her uncles also have a history of anxiety disorder.
Psychosocial History: The patient was raised by both her parents. She reports a history of emotional abuse, claiming to have been bullied as a child. She was changed to a private school, which led to no change. She also reports that her father was hard on her calling her a disappointment when her aunts would tell her that she was adopted. She claims to sleep very late at night for about 4 hours, due to nightmares. She enjoys watching television and reading thrillers. She confirms taking prenatal vitamins with a healthy diet.
Medical History: The patient reports that her last physical examination was on May 21st this year. She is currently under fertility therapy in preparation for pregnancy. She reports a history of gastritis and IBS.
Current Medications: Diazepam 2mg to help with sleeping some nights. Alprazolam 25mg once daily only for emergencies and letrozole 2.5mg daily for fertility treatment.
Allergies: Reports seasonal allergies.
Reproductive Hx: The patient is heterosexual and currently in fertility therapy in preparation for pregnancy.
Objective:
Diagnostic results: Thyroid function tests, toxicology screening, echocardiography, and blood glucose test may be obtained to rule out organic causes of the patient’s symptoms (Johnson et al., 2019). The Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire should also be utilized to monitor the patient’s anxiety disorder.
Assessment:
Mental Status Examination: The 34-year-old female patient is well-groomed in age-appropriate clothing. She is alert and well-oriented in person, place, and time. Her mother’s activity is unremarkable. She is cooperative during the interview and communicates in a clear and normal tone. Her mood is dysphoric. She displays a constricted affect, with good insight and judgment. Her memory is intact, with an unremarkable thought process. Her functional status is however mildly impaired.
Differential Diagnoses:
General Anxiety Disorder: GAD is a common mental disorder characterized by exaggeration, excessive anxiety, and worry every day for no apparent reason (Ströhle et al., 2018). Based on the DSM-V diagnostic criteria, the patient is positive for negative automated thinking, anxiety, and low self-esteem, in addition to nightmares, feelings of loneliness, difficulty in making decisions, dizziness, career choice difficulty, inferiority feeling, difficult keeping her job, headache, palpitations, dizziness, fatigue, stiff shoulders/neck racing thoughts, panic attacks, bowel disturbance and depression, which qualify for this diagnosis.
Major Depressive Disorder: According to the DSM-V diagnostic criteria, a patient must present with at least 5 of the following symptoms, such as sleep disturbance, fatigue, worthlessness, indecisiveness, recurrent thought of death, weight changes, depressed mood, and anhedonia (Schaakxs et al., 2018). The patient displayed most of these symptoms but was negative for suicidal ideation.
Social Phobia: This is an overwhelming and long-term fear of social situations (Nath et al., 2018). The patient reports problems with keeping her job, low self-esteem, and feeling lonely. She however does not meet the DSM-V diagnostic criteria for this disorder.
Reflections: The patient displays signs of general anxiety disorder. The PMHNP did an excellent job in collecting adequate information from the patient for more insight into her mental disorder. However, screening tools such as the Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire should have been used to monitor the patient’s GAD (Ströhle et al., 2018). Additionally, since the patient is an adult, the PMHNP has the ethical obligation of informing the patient about her condition and available treatment options for the patient to take part in making decisions concerning her health and attain her consent.
Case Formulation and Treatment Plan:
Diagnostic studies: Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire to monitor the patient’s anxiety symptoms (Johnson et al., 2019).
Referrals: The patient should be referred to a psychiatrist in case of poor response to current treatment or complicating comorbidity such as suicidality (Ströhle et al., 2018).
Therapeutic interventions. Advise the patient to continue taking her current medication such as diazepam 2mg to help with sleeping some nights; Alprazolam 25mg once daily only for emergencies. Consider psychotherapeutic approaches such as cognitive-behavioral therapy and mindfulness training (Ghahari et al., 2020).
Education: the patient needs to be educated on the importance of being consistent with therapy sessions and her medication for a positive outcome (Ströhle et al., 2018). She should also be advised on the relevance of exercise, good sleep, and a healthy diet in promoting her mental health.
Follow-up: Review the patient treatment plan after one to two months based on the outcome of the initial intervention.
References
Ghahari, S., Mohammadi-Hasel, K., Malakouti, S. K., & Roshanpajouh, M. (2020). Mindfulness-based cognitive therapy for a generalized anxiety disorder: A systematic review and meta-analysis. East Asian Archives of Psychiatry, 30(2), 52-56. https://search.informit.org/doi/10.3316/informit.310704814356937
Johnson, S. U., Ulvenes, P. G., Øktedalen, T., & Hoffart, A. (2019). Psychometric properties of the general anxiety disorder 7-item (GAD-7) scale in a heterogeneous psychiatric sample. Frontiers in psychology, 10, 1713. https://doi.org/10.3389/fpsyg.2019.01713
Nath, S., Ryan, E. G., Trevillion, K., Bick, D., Demilew, J., Milgrom, J., … & Howard, L. M. (2018). Prevalence and identification of anxiety disorders in pregnancy: the diagnostic accuracy of the two-item Generalised Anxiety Disorder scale (GAD-2). BMJ Open, 8(9), e023766. http://dx.doi.org/10.1136/bmjopen-2018-023766
Schaakxs, R., Comijs, H. C., Lamers, F., Kok, R. M., Beekman, A. T., & Penninx, B. W. (2018). Associations between age and the course of major depressive disorder: a 2-year longitudinal cohort study. The Lancet Psychiatry, 5(7), 581-590. https://doi.org/10.1016/S2215-0366(18)30166-4
Ströhle, A., Gensichen, J., & Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. Deutsches Ärzteblatt International, 115(37), 611. DOI: 10.3238/arztebl.2018.0611
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Advanced registered nurses work in highly collaborative environments and must collaborate with interdisciplinary teams in order to provide excellent patient care. Besides knowing the role and scope of one’s own practice, it is essential to understand the role and scope of other nurse specialties to ensure effective collaboration among nurses, the organization, and other professionals with whom advanced registered nurses regularly interact.
Use the “Nursing Roles Graphic Organizer Template” to differentiate how advanced registered nurse roles relate to and collaborate with different areas of nursing practice. Compare your future role with one of the following: nurse educator; nurse leader; family nurse practitioner; acute care nurse practitioner; graduate nurse with an emphasis/specialty in public health, health care administration, business, or informatics; clinical nurse specialist; doctor of nursing practice. Indicate in the appropriate columns on the template which roles you are comparing.
Make sure to compare the following areas of practice in your graphic organizer:
Ethics
Education
Leadership
Public Health
Health Care Administration
Informatics
Business/Finance
Specialty (e.g., Family, Acute Care)
Include any regulatory bodies or certification agencies that provide guidance or parameters on how these roles incorporate concepts into practice.
You are required to cite three to five sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content. Ensure that the country in the source is relevant to your paper. Sources cited should be generalizable to the population being studied or discussed.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are not required to submit this assignment to LopesWrite.
Attachments
NUR-513-RS-NursingRolesGraphicOrganizerTemplate.docx
Nursing Roles Graphic Organizer – Rubric
Collapse All
Comparison of Roles in Relation to Ethics 12 points
Criteria Description
Comparison of Roles in Relation to Ethics
Targeted 12 points
A comprehensive comparison of roles in relation to ethics is thoroughly developed with supporting details.
Acceptable 11.04 points
A comparison of roles in relation to ethics is clearly provided and well developed.
Approaching 10.56 points
A comparison of roles in relation to ethics is present.
Insufficient 9.6 points
A comparison of roles in relation to ethics is present, but it lacks detail or is incomplete.
Unsatisfactory 0 points
Comparison of Roles in Relation to Education 12 points
Criteria Description
Comparison of Roles in Relation to Education
Targeted 12 points
A comprehensive comparison of roles in relation to education is thoroughly developed with supporting details
Acceptable 11.04 points
A comparison of roles in relation to education is clearly provided and well developed.
Approaching 10.56 points
Comparison of Roles in Relation to Leadership12 points
Criteria Description
Comparison of Roles in Relation to Leadership
Comparison of Roles in Relation to Public Health 12 points
Criteria Description
Comparison of Roles in Relation to Public Health
Comparison Roles in Relation to Health Care Administration 12 points
Criteria Description
Comparison Roles in Relation to Health Care Administration
Comparison of Roles in Relation to Informatics 12 points
Criteria Description
Comparison of Roles in Relation to Informatics
Comparison of Roles in Relation to Business or Finance 12 points
Criteria Description
Comparison of Roles in Relation to Business or Finance
Comparison of Roles in Relation to Specialty 6 points
Criteria Description
Comparison of Roles in Relation to Specialty
Required Sources 6 points
Criteria Description Required Sources
Visual Appeal 6 points
Criteria Description Visual Appeal
Presentation 6 points
Criteria Description Presentation
Mechanics of Writing (includes spelling, punctuation, grammar, and language use)
6 points
Criteria Description
Mechanics of Writing (includes spelling, punctuation, grammar, and language use)
Documentation of Sources 6 points
Criteria Description
Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)
Targeted 6 points
Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.
Acceptable 5.52 points
Sources are documented, as appropriate to assignment and style, and format is mostly correct.
Approaching 5.28 points
Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.
Insufficient 4.8 points
Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.
Total 120 points
