PRAC 6645 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Subjective:

CC (chief complaint): ” I have no desire to do anything and find it difficult to get out of bed in the morning.”

HPI: M.C. is a 23-year-old Hispanic Female who presents to the facility for a psychiatric visit; the patient had previously been diagnosed with depression and anxiety and has been using Wellbutrin. The patient confesses to hearing strange voices once in a while and has a problem with sleep. The patient reports that, at times, she feels so exhausted and short of energy, and therefore, she struggles to get out of bed in the morning. She has also shown symptoms of a lack of interest in various activities she loves doing, such as going for a walk and reading novels. She reports that, at times, she has a lot of energy and feels like working non-stop without any rest. She has continually become forgetful and finds it difficult to concentrate both at work and at home.

Substance Current Use: The patient denies any current use of substances

Medical History: The patient has a history of depression and manages the symptoms using medication. She has no history of hospitalizations.

Current Medications: The patient currently uses Wellbutrin for depressive symptoms
Allergies:No records of known allergies

Reproductive Hx: The patient is sexually active and has a single boyfriend. She still has no children. She has regual menses. No cases of STIs indicated
ROS:
GENERAL: The patient has no distress and appears nourished and happy. However, she gets easily gets tired of questions she feels she doesn’t need to answer.
HEENT: No headaches, no dizziness, no eye or ear pain, no nasal discharge, no blurred vision or vision changes, no reports of swallowing difficulty
SKIN: No bruising, no lesions, no skin rash
CARDIOVASCULAR: no chest pain, breath shortness, or chest tightness
RESPIRATORY: No dyspnea, no cough, no reports of breathlessness
GASTROINTESTINAL: no constipation, stomach upset and diarrhea
GENITOURINARY: no frequent or urgent urination and no pain reported.
NEUROLOGICAL: no numbness, no headache, no ataxia
MUSCULOSKELETAL: no reports of muscle or joint pain.
HEMATOLOGIC: no bruising or bleeding
LYMPHATICS: no pain or swelling was reported
ENDOCRINOLOGIC: No polydipsia or polyuria. No heat or cold intolerance, no sweating.

Objective:

Temp 97.8 Pulse 88 Respiration 20 B/P 116/80

Laboratory Data Available: screening for alcohol and drug-using urine is negative. CMP and CBC are both within normal ranges.

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Assessment:

Mental Status Examination:

The patient is M.C., a 23-year-old Hispanic Female. The patient is appropriately dressed and well-groomed. She is also oriented to space and time. The patient is also alert. The patient’s thoughts are consistent with intact memory. She is positive for racing ideas and thoughts. The patient has pressured speech and, at times, talks louder than normal. She also talks a lot. The patient also finds it difficult to concentrate and easily gets distracted. The patient denies suicidal thoughts, actions, or ideations. She is positive for hallucinations as she hears strange voices at times.

PRAC 6645 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Diagnostic Impression:

Bipolar disorder: This is one of the most mood disorders which negatively impacts an individual’s life. The patient has shown various symptoms, such as talking more than usual, having racing ideas and thoughts, lack of energy, difficulty concentrating, and forgetfulness. She has also shown a lack of interest in various activities. Based on the DSM-5 diagnostic criteria, these symptoms are indicative of the presence of bipolar I disorder (Bayes & Parker, 2020)

Generalized Anxiety Disorder: The patient has shown various symptoms, such as racing thoughts and ideas. The patient has also experienced fatigue and finds it difficult to concentrate. In addition, over the last few days, the patient has been showing symptoms such as sleep complications as she finds it difficult to sleep, and she easily gets distracted from sleep, making generalized anxiety disorder a potential diagnosis. However, manic symptoms are majorly associated with bipolar disorder, making this condition less likely (DeMartini et al.,2019).

Borderline Personality Disorder: This is a condition that is majorly known for emotional instability and impulsivity (Gunderson et al.,2018). The patient has shown symptoms of emotional instability. Nonetheless, she has not shown impulsive behavior hence may make this condition to be ruled out.

Reflections:

The patient assessment carried out was key in the diagnosis process and revealing what the patient needs for improvement. The aspects which led to the diagnosis include the patient’s medical history, current medication, and mental health status assessment. These aspects should be performed as appropriate to help in creating the right management and treatment plan which can help the patient to recover from the condition. There are things I could do differently. For example, I would request to get more information from the patient’s boyfriend since he can give aadditional helpful information for better diagnosis and management of the patient. One social determinant of health that comes to play in this case is social support (Wang et al.,2018). The patient currently lives alone hence lacks appropriate social support to help her through the condition, therefore, there is a need to live with a close family member who can offer an all round support for better outcomes.

Medications form an integral part of the patient treatment and management process; therefore, sufficient medication education and health promotion should be provided to the patients and their family members (Kini & Ho, 2018). For example, they need to be informed of the dosage, the need to adhere to the medication regimen, and why it is important to seek medical attention in the case of adverse reactions or side effects. One aspect of health promotion is that the patient should be advised to stick to sleeping patterns to improve her sleeping habits and relaxing before going to bed. As part of the prescription and plan, the ethical principles should also be considered, and the practitioners should ensure that all the ethical principles are adhered to. Non-maleficence and autonomy should be considered in prescribing psychotropic medications to ensure that patients are safe and that their opinions are considered in the plans (Hunt Grubbe et al.,2020).

Case Formulation and Treatment Plan:

The assessment and diagnostic criteria mainly point to Bipolar I personality disorder. The patient has shown several symptoms which point to the condition, such as talking more than usual, having racing ideas and thoughts, lack of energy, difficulty concentrating, and forgetfulness. She has also shown a lack of interest in various activities, which she has enjoyed all her life. She also reported exhaustion, tiredness, and finding it hard to get up in the morning. It is, therefore, important for the patient to get appropriate medications to help manage the symptoms. The patient is already using Wellbutrin to manage depressive symptoms. Therefore, the patient should also start using Lamotrigine, 25 mg BID to help improve the symptoms (Hashimoto et al.,2021). For better outcomes, the patient also needs to commence psychotherapy sessions. As such, she needs to start weekly sessions of cognitive behavioral therapy. As part of the education, the patient should be informed of the potential side effects of Lamotrigine and when to stop using the medication if need be.

References

Bayes, A. J., & Parker, G. B. (2020). Differentiating borderline personality disorder (BPD) from bipolar disorder: diagnostic efficiency of DSM BPD criteria. Acta Psychiatrica Scandinavica, 141(2), 142-148. https://doi.org/10.1111/acps.13133

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49-ITC64. https://doi.org/10.7326/AITC201904020

Gunderson, J. G., Herpertz, S. C., Skodol, A. E., Torgersen, S., & Zanarini, M. C. (2018). Borderline personality disorder. Nature Reviews Disease Primers, 4(1), 1-20. https://doi.org/10.1038/nrdp.2018.29

Hashimoto, Y., Kotake, K., Watanabe, N., Fujiwara, T., & Sakamoto, S. (2021). Lamotrigine in the maintenance treatment of bipolar disorder. Cochrane Database of Systematic Reviews, (9). https://doi.org/10.1002/14651858.CD013575.pub2

Hunt-Grubbe, H. (2020). Ethical Issues Arising from the Prescription of Antipsychotic Medication in Clinical Forensic Settings. In Ethical Issues in Clinical Forensic Psychiatry (pp. 99-114). Springer, Cham. https://doi.org/10.1007/978-3-030-37301-6_6

Kini, V., & Ho, P. M. (2018). Interventions to improve medication adherence: A review. Jama, 320(23), 2461-2473. Doi: 10.1001/jama.2018.19271

Wang, J., Mann, F., Lloyd-Evans, B., Ma, R., & Johnson, S. (2018). Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatry, 18(1), 1-16. https://doi.org/10.1186/s12888-018-1736-5

PRAC 6645 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation