Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing psychotic disorders. Consider whether experiences of psychosis-related symptoms are always i
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Name: Ms. Jess Davies
Gender: female
Age: 30 years old
Background: Jess is brought for evaluation by her 2 roommates who are concerned with
behaviors. She had some issues with depression after aunt died but worsened in the 12 days after. She is only sleeping 2 hours/24hrs; she will only eat
canned foods. She smokes cannabis daily since she was 17 and goes out on weekdays couple
times with her roommates and has couple drinks of beer. She was prescribed alprazolam 1mg
twice daily as needed by her PCP for 15 days. She works in a bakery. Allergies: medical tape
Symptom Media. (Producer). (2016). Training title 24 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-24
Subjective:
CC (chief complaint): “they think am living in a movie”
HPI: Ms J .D, a 30yr old female was brought for psychiatric evaluation by her 2 roommates who had been concern about patient’s changed of behavior after her aunt died.her roomates states she had some issues with depression but it had gotten worse within the last 12 days. According to her background she only sleeps for 2hrs within a 24hr period, eats only canned food. She has been a smoker since the age of 17yrs. She was prescribed alprazolam 1mg twice daily as needed by her PCP for 15 days. During her evaluation patient states that some Russians are her neighbors
Past Psychiatric History:
General Statement: patient does not have any family psychiatric history, roomates confirmed patient has had issues with depression but no other psychiatric history confirmed. Patient is on alprazolam 1mg twice daily as needed but there is no indication for this medication
Caregivers (if applicable): none applicable
Hospitalizations: no known hospitalization documented
Medication trials: patient was prescribed alprazolam 1mg twice daily as needed. Pt states she stop taking the medication. No known psychotropic drugs identified
Psychotherapy or Previous Psychiatric Diagnosis: patient’s roomates states patient has an issue with depression after the death of her aunt. No known psychotherapy or psychiatric diagnosis confirmed.
Substance Current Use and History: smokes cannabis since the age of 17 years. Drinks couple of beer when out with roomamtes.
Family Psychiatric/Substance Use History: No known psychiatric or substance use history in patient’s family
Psychosocial History: Jess is a 30 yr old female who lives with her roomates. According to her background information patient goes out on weekdays couple times with her roommates and has couple drinks of beer. She works in a bakery. She lost her aunt recently and she witnessed her brother killed via GSW in a gas station burglary. She is estranged from her parents and her brother was her only sibling.
Medical History:
Current Medications: alprazolam 1mg twice daily as needed
Allergies: medical tape
Reproductive Hx: no known reproductive history.
ROS:
GENERAL: no fever, chills or weight loss reported.
HEENT: patient reported no visual changes, no hearing loss or running nose.
SKIN: No skin rash reported.
Cardiovascular: No chest pain, chest pressure, or chest discomfort reported.
RESPIRATORY: No SOB reported.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
GENITOURINARY: No burning sensation or urgency with voiding.
NEUROLOGICAL: No numbness or tingling sensation reported.
MUSCULOSKELETAL: No muscle back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes reported.
ENDOCRINOLOGIC: Patient report no signs of polyuria, sweating or heat tolerance.
Objective:
Physical exam: T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs
Diagnostic results: no diagnostic evaluation done however to help in the diagnosis of shizophrenia
Assessment:
Mental Status Examination:
Patient appears well groomed and dressed neatly, she appears restless and agitated with a lot of fidgeting and hand movement. Her behavior seem unprovoked but looks agitated, she keeps staring around which suggest that she could be responding to internal stimuli. Patient cannot sit still, she keeps fidgeting which could be a side effect from antipsychotics. Akathisia and dystonia are a side effect from antipsychotics, patients are fidgety and cannot sit still, they also exhibit repetitive facial movements, unnaturally twisting or flexing body parts. Patients’ speech and thought processes are disorganized and incoherent, she exhibits flight of ideas where she jumps from one topic to the other without making sense, her words are not connected in a logical way. EXAMPLE. She also exhibits tangentiality where she shifts thoughts and speech away from the original topic and does not return to the original points, This is when she
Mood her mood is somewhat appropriate although she exhibit agitation and restlessness, her affect is………… patient is experiencing persecutory delusions whereby she states Russian men and whores are her neighbor, she thinks if she is still the Russians cannot code her. She is also exhibiting Perceptual Disturbances which is hallucination, she seems to be responding to internal stimuli, patient exhibited auditory hallucination when she states “yes I hear them talking when no one else can, she also states she sees blueprints all over the walls which confirms visual hallucination. Cognitively patient is alert and oriented, her cognition is slightly impaired due to her thought processes. Patient has poor insight to her current situation, this is evidenced by not being compliant with her meds, she stops taking her medication and states that her medication is the problem to what she is going through. She is unaware of her symptoms and this confirms that her insight and judgement is impaired.
Differential Diagnoses:
Reflections:
References
