Comprehensive Psychiatric Evaluation And Patient Case Presentation

Comprehensive Psychiatric Evaluation And Patient Case Presentation

Comprehensive Psychiatric Evaluation and Patient Case Presentation

Chief Complaint

I don’t have to give my name, people are after me, and I have to be careful.”

 

V.O. is a 35-year-old African American female who presented to ED with erratic and bizarre behavior. Patient was brought in because she was walking in and out of traffic, not answering appropriately to police queries, yelling, screaming, and singing, refusing to tell her name, paranoid and delusional. During assessment patient furnishes delayed responses to queries, aloof and oblivious, to events going on around her, detached and internally preoccupied; responding to internal stimuli, impaired clarity of thought, disrupted train of thought, distracted and disorganized thought and behavior, suspicious, distrustful, and hypervigilant. (UDS is positive for THC, cocaine, methadone and ETOH level 84 and medication non-compliance. No drug/food allergies reported. No family history of psychiatric reported. Denies having suicidal/homicidal ideations denies feeling depressed and denies auditory hallucinations. Denies history of suicidal attempts Comprehensive Psychiatric Evaluation And Patient Case Presentation.

Vital sign: BP 131/65, P 74, R 16, T 97.5, SPO2 98%RA, Weight 149lbs

PAST PSYCHIATRIC HISTORY

Schizoaffective disorder bipolar type.

Patient has had multiple psychiatric hospitalizations in different hospitals

PAST MEDICAL HISTORY Comprehensive Psychiatric Evaluation And Patient Case Presentation

Asthma

PERSONAL/SOCIAL HISTORY

Patient reports being single, never married, have 2 children that live with their father, homeless, unemployed, and receive monthly SSI. HCG negative, UDS positive for THC, cocaine, methadone and ETOH level 84. Denies owning any firearms and denies any legal history.

MENTAL STATUS EXAMINATION:

Patient is alert and oriented to person and situation.

Appearance: Disheveled, Unkempt

Attitude: Anxious, distrustful, guarded, impulsive, suspicious Normal developed

Posture: rigid

Eye contact: downcast

Expression: blank

Speech: delayed, incoherent, minimal

Insight: poor

Judgment: poor

Affect: Irritable, labile

Mood Irritable

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Attention: distracted, poor attention

Memory immediate: intact

Memory recent past: intact

Memory remote past: intact

Thought process: flight of ideas, loose association, tangentiality, and withdrawal

Thought content: delusions

Perceptual Disturbance: hallucinations

Medications:

Risperdal 2 mg PO QHS for psychosis

Depakote ER 500 mg PO Q daily for mood

Ativan 2 mg IM q 4 hrs. PRN for anxiety

Haldol 5 mg IM q hrs. PRN for agitation

Benadryl 50 mg IM Q 6 hrs. PRN for EPS

Ambien 10 mg PO QHS PRN for insomnia

Flovent 220 mcg inhalers administer 2 puffs q 12 hrs. for SOB/Wheezing Comprehensive Psychiatric Evaluation And Patient Case Presentation.

Diagnosis

Paranoid schizophrenia

Polysubstance abuse

PLEASE ADD ONE MORE DIAGNOSIS TO MAKE IT 3 BASED ON THE CASE STUDY. Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning? Comprehensive Psychiatric Evaluation And Patient Case Presentation

· Objective: What observations did you make during the interview and review of systems?

· Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?

· Reflection notes: What would you do differently in a similar patient evaluation?

PLEASE ADD ONE MORE DIAGNOSIS TO MAKE IT 3 BASED ON THE CASE STUDY.

· Include at least five (5) scholarly resources to support the assessment and diagnostic reasoning Comprehensive Psychiatric Evaluation And Patient Case Presentation.