A comprehensive psychiatric case study is attached in file. Assistance is needed in the blue highlighted areas as followed (see attatch file to complete assignment) 1: Diagnostic results- this include

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): “Um, not sure why I am here. I guess because my mom brought me here.”

HPI: J.H is a 18 year old who was referred to AMHS by Riverside Behavioral Health Services. He was admitted there on 2/24/2023 and discharge on 3/13/2023. There, J.H was under a TDO after his mom took out a ECO for "being missing for three days" and concerns with him hearing the voice of Leonard Dicaprio. Jacob also had a violent outburst where he threw something through a glass door. He is unable to recall why he was hospitalized or why he is currently here at the office. Jacob reports no change in sleep habits. He reports 8 hours of sleep a night with no nightmares and sleep is uninterrupted. He currently reports no feeling of sadness, anxiety or mood changes. He currently denies any suicidal ideations. He denies seeing things but does admit to hearing voices at times. Jacob reports ear pieces in his ears tells him random things everyday, all day long. Per Jacob, this has been going for the past two months. He reports to over eat to alleviate hearing the voices. He also denies aggression or violence towards others but does feel homicidal towards people in video games. Anxiety is rated a 6/10 and he reports listening to rap music when feeling anxious. Jacob is unable to pin point what he feels anxious about or how often he is having these feelings. He is accompanied by his mother for this appointment (who has consent in his care) who was brought in later to get further insight on current background and reasoning for visit. Jacob was a poor historian when attempting to gain information during the interview process. Jacob began responding to internal stimuli at the completion of our session evidence by laughing to self and at inappropriate time. He was prescribed olanzapine 15 mg daily at bedtime and sertaline 50 mg daily. Jacob reports since discharged from the hospital he has been taking the medication daily as prescribed and has noticed his "mood is better"

Past Psychiatric History:

General Statement: Mr. Huff received outpatient mental health treatment . Per Jacob;s mother , Jacob was seen in 2013 for family therapy with Mr. Ralph at the Social Service Department on Warwick Blvd. in Newport News, VA
Caregivers mother
Hospitalizations: Mr. Huff has never been psychiatrically hospitalized.
Medication trials:Ritalin: years ago for ADHJD. This medication was previously taken but is not currently taken. Non compliance due to feeling medication was ineffective
Psychotherapy or Previous Psychiatric Diagnosis: Mr. Huff was diagnosed with ADHD. When the diagnosis was first made he was 9 years old. He was treated with medication for ADHD. The medication was Ritalin. The medication is described as having been ineffective.

Substance Current Use and History: Jacob reports that he vapes daily. Deniese any current or history of ETOH abuse

Family Psychiatric/Substance Use History: Paternal Grandmother known to have schizophrenia. Maternal Grandmother known to have schizophrenia. bipolar disorder.Mother denies history of substance abuse in family.

Psychosocial History: Mr. Huff was born in Norfolk, VA. He was raised by his parents, as part of an intact family at the present time. Mom was never married to Jacob's father but later married to a gentleman who is military affiliated. He is the second to the youngest of four children. Currently he lives at home with mom and older brother. He is a single make with no children. Mr. Huff is currently in 12th. Due to ADHD problems, and beng unable to focus and concentrate, he was removed from school in 8th grade to home school. He currently does not work and spends mpst of time home playing video game alone. He reports not having friends. Arrested for breaking and entering a "boat shop". This incident happened two months ago. Jacob goes to court May XX, 2023

Medical History:

Current Medications: olanzapine 15 mg at bedtime and sertraline 50 mg every morning
Allergies: NKDA or seasonal allergies
Reproductive Hx: non applicable

ROS:

GENERAL: no fever, chills, weakness or fatigue
HEENT: no vision loss, no blurred vision, no hearing loss
SKIN:
CARDIOVASCULAR: no itching
RESPIRATORY: no shortness of breath or cough
GASTROINTESTINAL: no nausea, vomiting or diarrhea
GENITOURINARY: none
NEUROLOGICAL:no headache, periods of forgetfulness
MUSCULOSKELETAL:no stiffness, no pain, steady gait
HEMATOLOGIC: none
LYMPHATICS: none
ENDOCRINOLOGIC: none

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination: Mr. Mr. Huff presents as flat, minimally communicative, disheveled with torn shoes and no socks and presents with poor hygiene, normal weight, and slow to respond. His speech is poorly articulated and slow to respond. Mr. Huff appears downcast. Thought content is depressed. Body posture and attitude convey an underlying depressed mood. Speech and thinking appear slowed by depressed mood. He denies having suicidal ideas. There is a thought disorder. Disorganized behavior has been observed. Bizarre behavior has been observed. Behavior suggests that auditory hallucinations are being experienced. The patient laughs inappropriately. Homicidal ideas or intentions are denied. Insight into problems appears fair. Judgment appears fair. There are no signs of anxiety. A short attention span is evident. He is easily distracted. Mr. Huff is fidgety. Mr. Huff made poor eye contact during the examination.

Differential Diagnoses: Mild intellectual disabilities, F70 (ICD-10) (Active)

Bipolar disorder, unspecified, F31.9 (ICD-10) (Active). Brief psychotic disorder;F23 (ICD-10).

Reflections:

PRECEPTOR VERFICIATION:

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