NRNP 6635 Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

Sample Answer for NRNP 6635 Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders Included After Question

By Day 7 of Week 7

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? 
  • Objective: What observations did you make during the psychiatric assessment?  
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

A Sample Answer For the Assignment: NRNP 6635 Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

Title: NRNP 6635 Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

Subjective:

CC (chief complaint): “My parents requested this appointment.”

HPI: Jay Feldman is a 19-year-old European-American male client on psychotherapy after his parents booked him a psychiatric appointment. When booking the appointment, Feldman’s parents reported that he was having difficulties in school. However, the client states that he is doing fine in school as a freshman pursuing Theoretical physics and advanced calculus. Feldman mentions that the combined courses are mysteries, and the moment he thinks that he has grasped it, it fades away. The client mentions that his roommate at State College brought a microwave. He reports that the purpose of the microwave is to trigger a bleeding degeneration of blood cells and bleed humanity from peoples’ rightful destiny. Feldman also mentions that their room is spying on them. The client has not been showering.

Past Psychiatric History:

  • General Statement: The client has a psychiatric history of mild paranoia.
  • Caregivers (if applicable): None
  • Hospitalizations: None
  • Medication trials: The patient was on a short trial of Aripiprazole for six months. The medication was stopped due to the side effects of akathisia.
  • Psychotherapy or Previous Psychiatric Diagnosis: Mild paranoia

Substance Current Use and History: Attempted to smoke marijuana twice at 18 years. He admits to taking vodka 3-4 glasses on weekends. Denies tobacco or other illicit substance use.

Family Psychiatric/Substance Use History: The patient has two younger brothers; one has a history of ADHD and the other a history of anxiety. Feldman’s mother has a history of anxiety, and his father of paranoia schizophrenia.

Psychosocial History:  Feldman is a freshman at State College pursuing a combination of Theoretical physics and Advanced calculus. He plans to pursue a double major in philosophy and physics. He is the firstborn in a family of three and was raised by both parents. He attained all his childhood developmental milestones. He states that he has several friends, but he has not kept in touch with them since he came back home. He sleeps 4–5 hrs per day.

Medical History:

  • Current Medications: None
  • Allergies: None
  • Reproductive Hx: No history of STIs.

ROS:

  • GENERAL: Reports appetite loss and weight loss. Denies fever, chills, or increased fatigue.
  • HEENT: Denies visual changes, ear pain/discharge, rhinorrhea, or swallowing difficulties.
  • SKIN: Denies rashes, discoloration, or bruises
  • CARDIOVASCULAR: Denies dyspnea, neck distension, or edema.
  • RESPIRATORY: Denies SOB, wheezing, or productive cough.
  • GASTROINTESTINAL: Reports having an inconsistent appetite. Denies having nausea, vomiting, abdominal discomfort, diarrhea, or constipation.
  • GENITOURINARY: Denies urinary symptoms.
  • NEUROLOGICAL:  Denies headache, dizziness, or muscle weakness.
  • MUSCULOSKELETAL: Denies joint stiffness/pain or muscle pain.
  • HEMATOLOGIC:  Denies bruising.
  • LYMPHATICS: Denies swollen lymph nodes.
  • ENDOCRINOLOGIC: Denies excessive sweating, heat/cold intolerance, or acute thirst.

Objective:

Physical exam: T- 98.3 P- 69 R 16 106/72 Ht 5’7 Wt 117lbs

Diagnostic results: None

Assessment:

Mental Status Examination:

The patient is untidy with shaggy hair, long dirty nails, yellow teeth, and a stinking body odor. He is alert but appears fatigued. He maintains minimal eye contact and appears uninterested in the interview. His speech is clear but speaks at a fast rate and high volume. The self-reported mood is “okay,” but he has a flat affect. He makes long pauses before responding to questions. He has a looseness of association, and his speech is difficult to follow. His thoughts are disorganized. The client has odd beliefs and paranoid delusions. No hallucinations, phobias, compulsions, or suicidal/homicidal ideations were noted. Insight is absent.

NRNP 6635 Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders
NRNP 6635 Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

Differential Diagnoses:

Schizophrenia: Schizophrenia is a psychotic disorder characterized by hallucinations, delusions, and problems with perception, thought, and behavior. The DSM-V criteria for diagnosing schizophrenia require the presence of two or more of the following psychotic features: Delusions, Hallucinations, Disorganized or catatonic behavior, Disorganized speech and Negative symptoms (McCutcheon et al., 2020). Schizophrenia is thus a differential diagnosis based on the patient’s symptoms of odd beliefs, paranoia delusions, looseness of association, and disorganized thoughts and speech. The patient’s symptoms have contributed to impairment in academic and self-care activities.

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Bipolar Disorder: Bipolar disorder is diagnosed based on the presence of alternating episodes of mania and profound depression. Mania is manifests with an elevated/irritable mood and increased goal-directed activity. Patients also present with grandiosity, excessive talking, racing thoughts, distractibility, diminished need for sleep, and increased engagement in risky activities (McIntyre et al., 2020). The episodes of profound depression present with a depressed mood, loss of interest, insomnia/hypersomnia, appetite changes, and suicidal ideations (McIntyre et al., 2020). Bipolar disorder is a differential based on the patient’s symptoms of looseness of association, reduced sleep, inconsistent appetite, and altered functioning in school and self-care areas. Nonetheless, the patient has no history of depression which makes Bipolar disorder an unlikely primary diagnosis.

Persecutory Delusional Disorder (PDD): Patients with PDD present with a persistent pattern of unwarrantable distrust and suspicion of others. They interpret others’ motives and actions as spiteful. Besides, individuals perceive that they may be attacked at any time and without reason (González-Rodríguez & Seeman, 2020). The patient’s paranoid delusions are consistent with PPD. The client believes that his roommate has brought a microwave to cause a bleeding degeneration of blood cells and bleed humanity from peoples’ rightful destiny. Besides, he expresses suspicions that they are being spied on in their room. However, the patient has looseness of association, and disorganized thoughts and speech, which are not characteristic of PPD, making it an unlikely primary diagnosis (Joseph & Siddiqui, 2021).

Reflections:

If I were to redo the session, I would assess the patient for depressive and anxiety symptoms, common comorbidities of schizophrenia. I would assess anxiety and depression using screening tools such as the Generalized Anxiety Disorder Assessment (GAD-7) and Patient Health Questionnaire- 9 (PHQ-9). The tools are effective in identifying the symptoms and their severity. Ethical principles to be considered in this patient include beneficence which is a duty to promote good and thus the best patient outcomes (Bipeta, 2019). Nonmaleficence should also be considered by avoiding causing harm to the patient. Health promotion interventions should include educating the patient on lifestyle changes such as increasing the level of physical activity and practicing healthy dietary habits.

References

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

González-Rodríguez, A., & Seeman, M. V. (2020). Addressing Delusions in Women and Men with Delusional Disorder: Key Points for Clinical Management. International Journal of Environmental Research and Public Health17(12), 4583.

Joseph, S. M., & Siddiqui, W. (2021). Delusional Disorder. In StatPearls. StatPearls Publishing.

McCutcheon, R. A., Reis Marques, T., & Howes, O. D. (2020). Schizophrenia-An Overview. JAMA Psychiatry77(2), 201–210. https://doi.org/10.1001/jamapsychiatry.2019.3360

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. Lancet (London, England), 396(10265), 1841–1856. https://doi.org/10.1016/S0140-6736(20)31544-0

A Sample Answer For the Assignment: NRNP 6635 Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

Title: NRNP 6635 Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

Subjective:

Chief Complaint: “Mr. Nehring suggested you see me. He said you are having some issues at work ”

History of Presenting Illness: F.B is a 27-year-old Caucasian female presenting for a psychiatric evaluation as recommended by her supervisor following allegations of issues at her workplace. She has a medical history of scoliosis and is currently under chiropractic care. She currently works as an administrative assistant in car sales. She lives alone and is an only child. She has had issues at her workplace. She has not been able to make any sales in three weeks. She feels that her supervisor is in love with her even though he has not done anything inappropriate. The supervisor has a girlfriend. F.B feels like her boss and her supervisor are ganging up against her to persecute her by firing her. She also believes that her boss is threatened by her being a strong woman who may replace him in his position. She also reports feeling pain in her neck that radiates to her back and thinks there is a lump on her back. She thinks this could be cancer. She believes that the ‘cancer’ is slowly killing her due to her supervisor’s obsession with her. She declines consultation with parents for collaborative history.

Past Psychiatric History: F.B’s past psychiatric history is unknown as she has declined to discuss her past psychiatric history and she also declined to consult with patients for a collaborative history.

Substance Current Use and History: FB reports no history of alcohol use or any substance abuse.

Psychosocial History: There is no mention of any history of psychiatric illness in the family. F.B’s family history is unclear as she has not disclosed much information about her family. There is no mention of a family history of diabetes, hypertension, cancer, or mental illness. F.B was raised by her parents. She is an only child. She lives in Coronado. She lives alone. She has a Bachelor’s degree in hospitality. She works as an administrative assistant in car sales. There is no reported history of trauma or violence in her life.

Medical History:

She has a medical history of scoliosis under treatment with chiropractic care.

  • Current Medications: F.B has no current medications. She is only under chiropractic care for managing scoliosis.
  • Allergies:She reports being allergic to latex, andno food or drug allergies were reported.
  • Reproductive History: F.B does not mention if she has borne any children, she has regular menses, she has no history of the use of contraceptives, and she has no history of treatment for any STIs. She practices vaginal intercourse.

ROS:

GENERAL: no weight loss reported, no fever, and no feeling of lethargy

  • HEENT: The head is of normal size, no obvious masses, normal hair distribution, no headache, the eyes are placed normally, no visual disturbances, no eye pain, no scleral jaundice, no conjunctival pallor, the ears are anatomically normal, no cerumen impaction, no auditory disturbances, No neck masses, no nasal congestion, or sore throat reported
  • Skin: No skin color changes, no swellings, no striae.
  • Cardiovascular: there is no edema of the extremities, no awareness of heartbeat, no dyspnea on exertion or orthopnea, there is no distention of the neck veins.
  • Respiratory: there is mild on and off cough, no shortness of breath, chest pain, hemoptysis, or chest tightness reported
  • Gastrointestinal: there is no reported vomiting, abdominal pain, change in bowel habits, diminished appetite, or bloody stool.
  • Genitourinary: there are no changes in urinary frequency, no burning sensation or pain during urination or coitus, no perineal itchiness or genital warts, and no perineal pain or ulcerations.
  • Neurological: there is no limb weakness or paralysis.
  • Musculoskeletal: There is no swelling, pain, change in color, or restricted range of motion in any of the joints.
  • Hematologic: there is no easy fatiguability or bleeding tendencies reported.
  • Lymphatics: There are no enlarged lymph nodes or spleen, and there is no unilateral leg swelling.
  • Endocrinologic: no changes in skin pigmentation, no heat intolerance, there is some level of unexplained lethargy, and there is emotional disturbances manifested as restlessness reported.

Objective:

Physical exam: vital signs: Temperature- 98.4, Pulse rate- 82, Respiratory rate 18, Blood Pressure 124/74mmHg  Height 5’0 Weight 118lbs.

Diagnostic results: Complete Blood Count, Thyroid function tests, Urea and Electrolytes, and Liver function tests are all within normal range

Assessment:

Mental Status Examination: F.B is a 27-year-old Caucasian female administrative assistant in car sales. She is of medium build and looks her stated age. She is well-kept and tidy. She is seated quietly although she is fidgety with minimal agitation.  She is oriented to time, place, and person with no abnormal movements or mannerisms. She appears concerned about her situation at her workplace and is preoccupied with the thought that her supervisor is in love with her. She appears guarded in manner. Emotionally, she appears tense. Her speech is of normal rate, volume, and coherence. Her mood is subjectively anxious. Her affect is mood congruent. Her stream of thought is coherent. She has persecutory delusions, referential delusions, somatic delusions, and erotomanic delusions. She is obsessed with the thoughts of being fired and of her supervisor being in love with her. She is generally anxious. She has no suicidal or homicidal ideations. There are no elicited perception disturbances like hallucinations or illusions. Her cognition, judgment, and insight are intact.

Primary Diagnosis: DSM-5 297.1 (F22) Delusional Disorder is the Primary diagnosis for F.B. She meets almost the whole of the diagnostic criteria for the diagnosis of the delusional disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). This patient exudes a myriad of subtypes of delusional disorder consisting of the erotomanic type, the persecutory type, and the somatic type, and she also shows delusions of reference. These are evidenced by the fact that she believes that her supervisor is in love with her despite strong evidence to the contrary since her supervisor has a girlfriend and has not shown any inappropriate actions towards her.

She also believes that her boss and her supervisor have colluded to fire her. She also reports having neck pain, back pain, and a lump on her back which is not factual. She also believes that when her supervisor asks for her opinion at work he is using that to be lustful. This is a referential delusion. The duration of the illness is not as clear. She has not been able to make a sale for three weeks now, inferentially, she has been unwell for a minimum of three weeks. This lack of clarity in the duration throws a shadow on the main diagnosis as it requires a minimum of one month of symptomatology.

Differential Diagnoses: 295.40 (F20.81) Schizophreniform Disorder, 298.8 (F23) Brief Psychotic Disorder (BPD), and 295.70 (F25.1) Schizoaffective Disorder Depressive type all qualify as possible differential diagnoses. Brief Psychotic disorder is a highly probable diagnosis as its diagnosis only requires one of the delusions, catatonia, hallucinations, and disoriented speech (Sadock & Sadock, 2021). This patient has delusions. BPD also meets the timeline factor of less than a month. There is not a single stressor that can be mapped out to qualify for BPD. The diagnostic distinction between delusional disorder and schizophreniform and schizophrenia illness lies in the duration of illness and symptomatology. Both schizophrenia and schizophreniform illness are heralded with hallucinations which are rare in Delusional disorder (González-Rodríguez & Seeman, 2022). This makes both schizophrenia and schizophreniform disorders unlikely. Schizoaffective disorder can be qualified with the presence of delusions for the duration of the patient’s illness (Miller & Black, 2019). However, there are no symptoms of a major mood disorder that are shown by the patient.

Reflections: F.B presents with delusions which are classic symptoms of a psychotic disorder. However, having discussed the main diagnosis and the differential diagnoses, I realized there is a thin line that separates Delusional Disorder (DD) and Brief Psychotic Disorder (BPD). This lies in the duration of illness which from the case, is not clear. If I were to redo this case, I would inquire how and when the symptoms began. There is a lot of missing information on the family history of mental illness, personal history, and treatment history that I think would be crucial in the management of this case (Sarin et al., 2018). Proper patient management requires full disclosure of the health condition and history. Due to the limited disclosure, in this case, quality and effective care is almost an impossible phenomenon (Zolkefli, 2018). The most intriguing issue of ethical concern, in this case, is the operational challenges in the diagnosis and treatment; specifically in this case is inadequate information to make an extensively informed decision.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th edition).

González-Rodríguez, A., & Seeman, M. V. (2022). Differences between delusional disorder and schizophrenia: A mini-narrative review. World Journal of Psychiatry, 12(5), 683–692. https://doi.org/10.5498/wjp.v12.i5.683

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of Clinical Psychiatry: Official Journal of the American Academy of Clinical Psychiatrists, 31(1), 47–53. https://pubmed.ncbi.nlm.nih.gov/30699217/

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer.

Sarin, A., Jain, S., & Murthy, P. (2018). Turning the pages, or why history is important to psychiatry. Indian Journal of Psychiatry, 60(Suppl 2), S174–S176. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_429_17 Zolkefli, Y. (2018). The Ethics of Truth-Telling in Health-Care Settings. Malaysian Journal of Medical Sciences, 25(3), 135–139. https://doi.org/10.21315/mjms2018.25.3.14