Based on the following comprehensive psychiatric evaluation and information provided, please complete the following: differential diagnosis (at least three with one being a mood disorder)reflectionsca

PRAC 6645 Comprehensive Psychiatric Evaluation Template

Week #4: Comprehensive Psychiatric Evaluation

Shannon Pierce

College of Nursing-PMHNP, Walden University

PRAC 6645: Psychopathology and Diagnostic Reasoning

Dr. F. Anugom

June 22, 2023

Subjective:

CC (chief complaint): “Yeah I was using a lot of opiates and marijuana, and I verbalized I wanted to kill myself at the hospital.”

HPI: patient is a 38-year-old white admitted to the Pavilion on a TDO. He is referred by the CSB as a TDO and is medically cleared at current health care facility. Patient presents with thoughts of harming self and had a plan to overdose on his medications. He has previously attempted suicide by overdose in January 2023. He has been hearing voices that are telling him to hurt himself. He denies homicidal ideation as well as paranoia.

ROS General: well nourished, well developed white male in no acute distress, cooperative with mildly pressured speech.

EENT: visual changes, no hearing changes, no change in smell or taste, no difficulty swallowing

CARDIAC: normal RR, no, murmurs, no chest pain

RESPIRATORY: lungs clear, no reports of shortness of breath

GASTROINTESTINAL positive for vomiting x3 days

URINARY: dysuria

MUSCULOSKELETAL: joint and back pain (left ankle and back) rated 3/10 on a scale 1-10 with 10 being most severe, described as sharp, throbbing, and nagging pain.

NEUROLOGICAL tremors noted, AOx3.

ENDORINE: denies.

PSYCHOLOGICAL: auditory hallucination, no paranoia. SI

Past Psychiatric History:

General Statement: patient has been in treatment for a few years for opiate use. Patients have been seen in the past for mental health illness and have not followed through with recommended outpatient treatment each time.
Caregivers (if applicable): patient currently lives with his father.
Hospitalizations: Patient has been experiencing detox from opiates. This is the patient’s third inpatient hospitalization for SI and detox. Last hospitalization was noted in January 2023 for SI with a plan to overdose on medications.
Medication trials: Buspar 5 mg daily, catapress 0.1 mg daily, voltaren 1% topical gel PRN for chronic pain, Cymbalta 20 mg in AM and 60 mg in PM, Atarax 50 mg PRN every 6 hours, Mobic 15 mg daily, Robaxin 750mg every eight hours PRN, Remeron 15 mg at HS, Seroquel 300 mg at HS, MVI once daily and trazodone 50 mg at night PRN ( these are home medications but have been stopped while receiving inpatient services)
Psychotherapy or Previous Psychiatric Diagnosis: Previous diagnosis include, MDD, Bipolar type, substance use related to cannabis dependency, and schizoaffective disorder.

Substance Current Use and History: marijuana daily, smokes less than a half pack of cigarettes daily and no reports of alcohol use

Family Psychiatric/Substance Use History: per patient no reports of mental illness, father does drink daily.

Psychosocial History: patient was born and raised in Danville, VA. Patient had both mother and father in household but is currently living with father. The patient has one younger brother who is currently away overseas for military duty. Patient and brothers’ relationship is not on good standings. Patient is currently single and has no children. Patient dropped out of high school in 10th grade but did obtain his GED. Patient currently does not face any legal issues. The patient is currently unemployed and receiving disability. Patient enjoys listening to music and making things with his hands in his spare time.

Medical History: chronic back pain and GERD

Current Medications: Suboxone 8mg/2mg Sublingual one film daily for addition, Bupropion ERT 150 mg daily for depression, Zofran 4 mg every four hours PRN nausea, Tylenol 650 mg every four hours for pain, Mylanta 30 ml every four hours for indigestion, Motrin 600 mg every six hours for musculoskeletal pain, MOM 30 ml daily for constipation
Allergies: NKDA and no food allergies reported
Reproductive Hx: N/A

Objective:

Diagnostic results: EKG normal sinus rhythm with no acute ST or T wave changes, BAL negative, CBC, UA with 1+ protein, trace ketones and 2+ blood with greater than 50 RBCs, urine screen is positive for cannabis.

Assessment:

Mental Status Examination: He is a 38-year-old Caucasian male who appears his stated age. He is well groomed and developed and with no odor noted. No evidence of gait disturbance, balance is normal, no ataxia and maintains good posture. There is evidence of tremors as patient reports he may be experiencing withdrawal from opiates. His speech is clear and coherent but soft, barely audible at times. His thought process is logical with no evidence of loose association or flights of ideas and no paranoia. His mood is normal, and his affect is appropriate for his mood. There is no delusional thinking. He does reports auditory hallucinations with voices telling him to hurt himself. Currently he denies suicidal and homicidal ideation. Cognitively he is alert and oriented to his name, date, location, and situation. Memory is intact with good insight and judgement.

Differential Diagnoses:

Reflections:

Case Formulation and Treatment Plan:

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