Comprehensive Psychiatric Evaluation Notes

CC : « I would like to know how to manage my Anger and anxiety « 

30 year old African American female . (NL) Came today for intake interview, complained of anxiety and short fews,(anger not able to control).patient is 5’4 ‘, weight 160 lbs,has 4 children, 1 miscarriage last year, she is in a relationship but they don’t live together, planning on getting married.has 3 years of college, patient complained of difficulty concentrating , math was very difficult for her,was raised with biological mother and father lives with  2 brothers and 1 foster sister in which she is not talking today,grandma lives with them(Comprehensive Psychiatric Evaluation Notes Essay Example).Family history of mental illness on father side, patient stated she thinks her father is a narcissist, he was abusive to the mother, and verbally abusive to the children.one uncle on the father side committed suicide.in 2008 first psychiatric breakdown where she punched holes threw the wall ; she was sexually promiscuous where she will have two relationships, she was married got pregnant by another man, she was having intercourse with more then one man,she loves being pregnant ,age of 20 got married got pregnant by another man.patients stated she used to love to go to the hospital to have those babies because of the attention she used to get when she was pregnant and go to the hospital , she loves the attention she was getting when she was in labor. She was malested  when she was in 3rd grade, 13 years and 16 years was malested again,at the aged of 20 patients was diagnosed with bipolar 2 disorder was put on Cytalopram  10 mg po daily, bupropion 150mg daily, patient complained of being hyperactive not being able to focus,short tamper , no medical problem.(Comprehensive Psychiatric Evaluation Notes Essay Example)

Tx : psychotherapy weekly, lamotrigine 50 mg po bid,Atomoxetine 10 po in AM F/U in one week.

DX : Bipolar 1 disorder, ADHD, GAD.

Comprehensive Psychiatric Evaluation Notes Essay Example

Subjective:

CC (chief complaint): “I am overwhelmed with anxiety. I have difficulty controlling my temper.”

HPI: NL is a 30-year-old African American female present for an intake interview. The patient reports feeling overwhelmed with anxiety and having difficulty controlling her temper. She also reports difficulty with concentration, particularly in regard to mathematics. She reports having her first psychiatric breakdown in which she punched holes in a wall. She reports having sexual promiscuity and having sexual intercourse with more than one man. She was in two relationships, married by one man and pregnant for another at age 20. She loves being pregnant and could go to the hospital to get attention from babies as she used to while pregnant and in labor. The client reports being hyperactive and short-tempered. She has a problem focusing and has no history of significant medical issues.(Comprehensive Psychiatric Evaluation Notes Essay Example)

Past Psychiatric History: The patient reports a history of psychiatric breakdown in 2008, during which she punched holes in the walls. She reports being diagnosed with Bipolar 2 Disorder at the age of 20. She reports feeling hyperactive and unable to focus, with a short temper.(Comprehensive Psychiatric Evaluation Notes Essay Example)

General Statement: The client was treated for bipolar two disorder

Caregivers (if applicable): N/A

Hospitalizations: Not indicated.

Medication trials: Tried Citalopram 10 mg PO daily and Bupropion 150 mg daily for bipolar two disorder.

Psychotherapy or Previous Psychiatric Diagnosis: The client has a history of Bipolar 2 Disorder aged 20.

Substance Current Use and History Denies alcohol and substance abuse.

Family Psychiatric/Substance Use History: The client believes her father is narcissistic. The father was abusive to the mother and verbally abused her siblings. One of her uncles committed suicide.

Psychosocial History: Born and raised by biological mother and father. Has two brothers and a foster sister. She does not talk to her foster sister. They live with their grandmother. The patient is in a relationship, but they do not live together, though they are planning to get married. She was molested three times in grade 3 and at ages 13 and 16.(Comprehensive Psychiatric Evaluation Notes Essay Example)

Medical History: No significant medical history.

Current Medications: None

Allergies: NKFDA

Reproductive Hx: Sexually active. G5, P4, A1

Objective:

ROS:

• GENERAL: Denies weight loss, fever, or chills.
• HEENT: No visual or hearing loss. No nasal congestion or sore throat.
• SKIN: Has normal skin turgor.(Comprehensive Psychiatric Evaluation Notes Essay Example)
• CARDIOVASCULAR: No chest discomfort, pain, or pressure.
• RESPIRATORY: No breathing difficulty.
• GASTROINTESTINAL: No abdominal pain, nausea, vomiting, or diarrhea.
• GENITOURINARY: No urination urgency, burning sensation, hesitancy, or odor.
• NEUROLOGICAL: No history of passing out, numbness, paralysis, or tingling in the extremities. No change in bowel or bladder control.(Comprehensive Psychiatric Evaluation Notes Essay Example)
• MUSCULOSKELETAL: No back pain. No joint pain or muscle stiffness.
• HEMATOLOGIC: No ease of bleeding, bruising, or anemia.
• LYMPHATICS: No enlarged nodes. No history of splenectomy.
• ENDOCRINOLOGIC: No history of cold, sweat, or heat intolerance. No polyuria or polydipsia.

Objective:

Physical exam: NA

Vital Signs: T- 98.7 R 16 119/74 Ht 5’4″ Wt 160lbs, BMI = 27.5 kg/m²   (Overweight)

Diagnostic results:

Lab Findings: WNL

Tox Screen: Negative for Nicotine and Alcohol.

Assessment:

Mental Status Examination:

The client appears well-kempt and oriented. She is cooperative and presents with a euthymic mood. The thought process is tangential but goal-directed. The sign of delusional thought content was noted during the interview. The client’s perception does not demonstrate illusions or auditory/visual hallucinations. The client’s judgment and insight are fair. No past or present suicidal or homicidal ideation is noted during the exam.(Comprehensive Psychiatric Evaluation Notes Essay Example)

Differential Diagnoses:

1. 44 (F31.2), Bipolar I Disorder With anxious distress – The DSM-5 criterion for bipolar one disorder includes a manic episode and past or present major depression or hypomanic episodes. The condition is associated with irritability or elevated mood symptoms characterized by increased energy in activities (American Psychiatric Association [APA], 2019). Other vital symptoms are distractibility, talkativeness, elevated self-esteem, psychomotor agitation, hypersomnia, flight of ideas, and harmful activities (APA, 2019). During depressive moods, individuals experience a period of displeasure in routine activities for most days, recurrent thoughts of death, loss or gain, low energy, worthlessness, hypersomnia/insomnia, and difficulty focusing and concentrating.(Comprehensive Psychiatric Evaluation Notes Essay Example)
2. 01 (F90.2), Combined presentation ADHD – The DSM-5 criteria for combined ADHD include a period of inattention and hyperactivity that has been present for more than six months (APA, 2019). During inattention, individuals do not give attention to details, make careless mistakes, cannot sustain attention, are easily distracted, cannot follow instructions, lose things, are easily distracted, forgetful, and reluctant to engage in activities that require sustained attention.
3. 02 (F41.1), GAD –The DSM-5 criteria for GAD include symptoms such as persistent worry or anxiety and inability to control the anxiety (APA, 2019). The worry-related symptoms include irritability, inability to concentrate, muscle tension, sleep disturbances, loss of energy, and restlessness. These symptoms are associated with significant distress and impact multiple other areas of functioning, including occupational, social, and academic activities.(Comprehensive Psychiatric Evaluation Notes Essay Example)

Reflections:

Bipolar I disorder is the primary diagnosis. The client presents symptoms that suggest a present hypomanic episode and a history of major depression. The client reports a period in which she demonstrated high energy towards sexual activity, getting pregnant, and going to the hospital to get attention which also suggests a goal-directed and harmful activity. The client reports punching holes in the wall in her first psychiatric breakdown, which shows engagement in a harmful activity and a history of intense emotional distress. Besides, the client reports having difficulties concentrating or sustaining attention, which further suggests bipolar one disorder. Generally, depressive episodes, anxiety, eating disorders, or substance abuse precedes bipolar one disorder (APA, 2019). Therefore, bipolar I disorder is the primary diagnosis.(Comprehensive Psychiatric Evaluation Notes Essay Example)

However, some of the client’s symptoms suggest ADHD and GAD. For instance, the client’s symptoms of psychiatric breakdown, punching holes on the wall, difficulty focussing, increased activity related to sexual indiscretions, and short temperament suggest combined ADHD presentation. However, the diagnosis is refuted since the client does not experience six or more of the DSM-5 provided inattention and hyperactivity symptoms. Besides, most ADHD symptoms should be experienced before age 12, which is invalid in this case. On the other hand, the client’s symptoms, such as being overwhelmed with anxiety and having difficulty controlling her temper, suggest GAD. However, the client does not present key symptoms that constitute the diagnostic criteria for GAD. The GAD-related symptoms presented by the client do not meet the diagnosis criteria. Therefore, the diagnosis is refuted.(Comprehensive Psychiatric Evaluation Notes Essay Example)

A practitioner should consider upholding confidentiality and informed consent. Considering the comorbid nature of bipolar one disorder and ADHD (Boland & Verduin, 2021), a practitioner should consider providing the client with information regarding her condition, the benefit of psychiatric evaluation, and the risks associated with the lack of treatment. Besides, a practitioner should assure the client of intentions to secure the contents of the psychiatric assessment and treatment plan unless otherwise to gain trust and establish an appropriate therapeutic alliance. The therapeutic alliance will be crucial in promoting getting more information to facilitate a definitive diagnosis.(Comprehensive Psychiatric Evaluation Notes Essay Example)

Case Formulation and Treatment Plan:

Pharmacotherapy

The patient will be started on lamotrigine 50 mg PO bid and Atomoxetine 10 mg PO in the AM. Lamotrigine is indicated for and effectively manages symptoms associated with bipolar disorders (Tuzimski & Petruczynik, 2020). Atomoxetine is effective for treating inattention in adults and is well-tolerated (Clemow et al., 2017).(Comprehensive Psychiatric Evaluation Notes Essay Example)

Psychotherapy

She will also receive weekly psychotherapy sessions. The psychotherapy will be based on a family-focused therapy approach. Family-focused therapy will incorporate psychoeducation, management of stressors, communication enhancement, and problem-solving sessions (Boland & Verduin, 2021).(Comprehensive Psychiatric Evaluation Notes Essay Example)

Refer the client to a dietician for weight management.

A follow-up appointment will be scheduled for one week. Further assessment is needed to determine if additional psychiatric diagnoses are present and if a personality disorder contributes to the patient’s presentation.(Comprehensive Psychiatric Evaluation Notes Essay Example)

References

American Psychiatric Association (APA). (2019). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing(Comprehensive Psychiatric Evaluation Notes Essay Example)

Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian journal of psychological medicine, 41(2), 108-112. https://doi.org/10.4103%2FIJPSYM.IJPSYM_59_19(Comprehensive Psychiatric Evaluation Notes Essay Example)

Boland, R., & Verduin, M. (2021). Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Lippincott Williams & Wilkins.

Clemow, D. B., Mason, O. W., Sarkis, E. H., Ruff, D. D., Berman, B. D., Donnelly, C. L., … & Araujo, A. B. (2017). Atomoxetine monotherapy compared with combination therapy for the treatment of ADHD: a retrospective chart review study. Expert Review of Neurotherapeutics, 15(11), 1353-1366. https://doi.org/10.2147%2FNDT.S115707

Tuzimski, T., & Petruczynik, A. (2020). Review of chromatographic methods coupled with modern detection techniques applied in the therapeutic drugs monitoring (TDM). Molecules, 25(17), 4026. https://doi.org/10.1002%2F14651858.CD013575(Comprehensive Psychiatric Evaluation Notes Essay Example)