Psychopathology And Diagnostic Reasoning paper
Psychopathology And Diagnostic Reasoning paper
Subjective Section
Chief complaint: excessive fear and insomnia for over six months
History of present illness (HPI)
Sergeant Patrick Flanery is a 27years old male accompanied by his mother to the emergency department due to excessive fear and insomnia for over six months. The excessive fear and worry started one year ago while he was in the military. The mother reports that his son experiences intrusive thoughts related to traumatic events (exporting dead bodies, killing enemies, and brutality among innocent citizens and his colleagues). He also experiences nightmares and flashbacks that have contributed to negative emotional reactions. He reports that he rarely falls asleep due to the fear of nightmares and flashbacks. This has affected his daily activities and concentration span. The mother reports the son has persistent negative beliefs and expectations about himself. He has increased agitation and anger outbursts. The patient avoids people, places, and other activities. However, he denies suicidal ideation, self-harm, and hopelessness. Psychopathology And Diagnostic Reasoning paper
Past psychiatric history: the patient denies having mental health illnesses
Medication trials and current medications: the patient takes prednisone 10mg PO OD for seasonal allergies. He takes a Salbutamol inhaler 200mcg at acute exacerbation of asthma.
Psychotherapy or previous psychiatric diagnosis: the patient denies psychiatric and psychotherapy events.
Pertinent substance use: the patient denies use of alcohol and other substances
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Family psychiatric/substance use: the patient is the second born in a family of three. He has an elder sister and a younger sister. His parents are alive but he describes his father as a sloppy drunk. However, he does not abuse other drugs. He lives with diabetes mellitus, hypertension, and liver disease. His mother is alive and healthy. She takes care of his father. Her siblings are alive and healthy. His paternal grandfather used to alcohol and suffered depression at times. He denies a family history of cancer and suicidal issues.
Social history: the patient is the second born in his family. He lives in a different state from his family and siblings. He lives with his fiancé and hopes to marry her within two years. He wishes to have children after he marries. The patient has studied up to high school then joined the military. He states that he grew up poor and he would not do much if he never joined the military. He is currently working as a furniture salesman. He worked in the military for eight years where he worked for three long tours in the warzones and left less than one year ago. He neither takes alcohol nor abuses other drugs. The patient enjoys reading books, traveling, and swimming.
Legal history: the patient denies past and current legal issues.
Trauma history: the patient reports experiencing traumatic events when he was working in the military. The traumatic events include exporting dead bodies, killing enemies, and brutality among innocent citizens.
Violence: the patient has experienced physical violence several times while working in the military. However, he denies sexual harassment.
Medical history: the patient has service-connected asthma and seasonal allergies. However, he denies hospital admission, blood transfusion, and lifestyle diseases. He has never undergone major and minor surgical procedures, convulsions, and head injuries.
Allergies: the patient is allergic to dust, fur, and cold weather which presents with a rash and congestion when exposed to. However, he has no known food and drug allergy.
Review Of Systems
General: the patient denies fatigue fever, weight loss, chills, and rigors.
HEENT: the patient denies eye pain, blurring of vision, visual loss, and lacrimation. He denies hearing loss, ear discharge, and ear pain. he denies throat pain, running nose, nasal congestion, and hoarseness of the voice.
Respiratory system: the patient denies cough, chest pain, wheezing, shortness of breath, tachypnea, and sputum production.
Cardiovascular system: the patient denies chest pain, palpitations, shortness of breath, syncope, orthopnea, and paroxysmal nocturnal dyspnea.
Skin: the patient denies a change of skin color, rash, stretch marks, and itchiness.
Gastrointestinal system: the patient denies abdominal pain, reflux, nausea, vomiting, diarrhea, constipation, and heartburn.
Genitourinary system: the patient denies dysuria, hematuria, urine incontinence, urgency, polyuria, and oliguria.
Neurological system: the patient denies numbness, paralysis, facial droop, tingling sensation, and tremors.
Musculoskeletal system: the patient denies joint pain, muscle pain, stiffness, numbness, and muscle spasm.
Hematologic system: the patient denies bleeding tendencies, easy bruising, and dizziness.
Endocrine system: the patient denies heat intolerance, night sweats, abnormal weight shift, stretch marks, and agitation,
Lymphatic system: the patient denies lower limb swelling, enlargement of the spleen, and lymphadenopathy.
Objective Data
General: the patient is alert and oriented. He appears healthy for age, height, and weight. He has no pallor, jaundice, dehydration, edema, or lymphadenopathy. Psychopathology And Diagnostic Reasoning paper
Vitals: the temperature is at 97.4, Pulse rate 84, Respiratory rate at 18, Blood Pressure at 134/88, Height 5’8, and weight 167lbs.
Respiratory system: there is asymmetrical chest expansion. The skin color is uniform across the chest. There are no scars or bruises, and no obvious swelling. There is a resonant percussion note. The lung fields are clear upon auscultation. There is no stridor, wheezing, rhonchi, or crackles.
Cardiovascular system: the heart is normally active at the 5th ICS MCL. The heart sounds S1 S2 is present. There are no palpable parasternal heaves and thrills. There are no murmurs. The pulse rate is has a regular rate and rhythm.
Abdomen: the abdomen is round with uniform skin color. There is no flank fullness. However, the bowel sounds are present in the four quadrants. There is no tenderness or organ enlargement. There is no shifting dullness.
Musculoskeletal system: there is no swelling of joints. The muscle bulk, power, and tone are normal in the four limbs. The reflexes are present and normal. The patient assumes an upright posture and gait.
Mental status examination:
The patient is neat and appropriately dressed for the weather and the event. The patient is hyper-vigilant and is very keen on what is happening in the surrounding. He barely maintains eye contact. He makes inappropriate movements during the interview. His speech has a soft tone and low volume. He appears to have a flight of ideas because he has a pressured speech when describing the traumatic events. The patient seems to be anxious and exhausted. His emotional range is restricted and has persistent negative emotions. The thought content includes negative beliefs of himself, anger, and persistent vision of the traumatic event. His concentration level is low and portrays amnesia regarding the traumatic events. However, he has no visual or auditory hallucinations, delusions, and suicidal ideation. The judgment and insight are good.
Assessment
Differential Diagnosis
Post-traumatic stress disorder
Anxiety disorders
Post-traumatic stress disorder is an acute mental illness resulting from recurrent exposure to traumatic events. The clinical presentations are excessive fear or worry, sleep disturbances, irritability, avoidance of the traumatic triggers, and persistent intrusive thoughts related to the traumatic events. Patients with PTSD have experienced one or more traumatic event that is persistent re-experiences and alters their cognitive function and mood (Meneses, et al, 2021). These symptoms may last for over one month and are not attributable to physiologic effects of medical diseases or substance use. The American psychiatric association DSM-V criteria for diagnosis includes irritable behavior, sleep disturbance, concentration problem, anger outbursts, persistent and exaggerated negative beliefs, avoidance of people and activities, nightmare, flashbacks, and intrusive thoughts of the traumatic events. Psychopathology And Diagnostic Reasoning paper
Anxiety disorders are the most common psychiatric disorder characterized by restlessness, irritability, sleep disturbance, muscle tension, difficulties in concentration, and fatigue. Anxiety disorders can be social phobias, panic disorders, generalized anxiety disorders, and agoraphobia. Patients with anxiety disorders may present with palpitation, sweating, trembling or shaking, chest pain, de-realization, and fear of losing control (Jacobson, et al, 2021). Causes of anxiety disorders are childhood traumas, genetic predisposition, drugs and substance abuse, and chronic diseases.
Obsessive-compulsive disorder is a mental illness that presents with a recurrent pattern of unwanted thoughts and obsession that leads to repetitive behavior. These compulsions and obsessions alter the patient’s daily activities. Causes of OCD are genetic predisposition, infectious diseases, stress, and parenting styles (Halvorsen, et al, 2021). The presenting signs and symptoms are recurrent thoughts that are experienced at some time and cause anxiety, suicidal ideation, negative thoughts about oneself.
Critical Thinking Process
The primary diagnosis is post-traumatic stress disorder because of the presenting symptoms and mental state examination findings. The presenting symptoms are insomnia, fear, intrusive thoughts of the traumatic events, nightmares, flashbacks, isolation from other people, negative emotions towards himself, and loss of concentration. The patient experienced traumatic events that have affected his daily activities, cognitive activities, and mood. Psychopathology And Diagnostic Reasoning paper
Reflection Note
The experience of assessing a patient with mental health illness was quite challenging because of the pressure in his speech and thought block. It was hard to establish his mood and affect. However, the patient was cooperative throughout the interview. In the next session, I will ask more direct questions to enable the patient to answer what is asked. I will ensure there is privacy and confidentiality.
Health Promotion
Patients fear disclosing their feelings, emotions, and thoughts due to the fear of judgment by their peers. In addition, there are myths such as soccer are associated with mental illnesses. However, these myths and stigma are eradicated by creating mental awareness campaigns to sensitize the community. These campaigns involve teaching the common diseases and their presenting signs and symptoms (Galante, et al, 2021). This promotes early diagnosis and treatment. The psychiatrists and psychotherapists should provide a clear guideline for a basic mental health assessment to make the appropriate diagnosis.
Assignment: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD “Fear,” according to the DSM-5, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2013). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease. Photo Credit: Hill Street Studios / Blend Images / Getty Images For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5 criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5 criteria. To Prepare: • Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing anxiety, obsessive-compulsive, and trauma- and stressor-related disorders. • Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document. • By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind. • Consider what history would be necessary to collect from this patient. • Consider what interview questions you would need to ask this patient. • Identify at least three possible differential diagnoses for the patient. By Day 7 of Week 4 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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.). Selected case study videos https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-21 Training Title 21 Name: Sergeant Patrick Flanrey Gender: male Age:27 years old T- 97.4 P- 84 R 18 B/P134/88 Ht 5’8 Wt 167lbs Background: He entered the military just after high school and did three long tours of duty in warzones. He separated from active duty in the Marines (MOS 0800 Field Artillery) less than a year ago after eight years of service. He is engaged to be married (no date set) and is currently working as a furniture salesman. He said he grew up poor and would not do much else if he didn’t go into the military. He denies ever using any drugs and avoids alcohol because his father was “sloppy drunk.” Father is still alive, unwell (DM, liver disease, HTN), still drinking. Paternal grandfather was also a veteran and suffered depression at times though he never told anyone except the patient because of their combat connection. Mother is alive and well, still “caring for dad.” He has one younger and one older sister. He lives in a different state, approximately five hours from his parents and siblings. After the military, he and his fiancé moved because she got a much better opportunity. They want kids someday and hope to marry in a year or two. Has service-connected asthma, seasonal allergies; no hx of psychiatric or substance use treatment. Symptom Media. (Producer). (2016). Training title 21 [Video]. https://video-alexanderstreet com.ezp.waldenulibrary.org/watch/training-title-21 Required readings to complete assignments https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1176/appi.books.9780890425596.dsm05 https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1176/appi.books.9780890425596.dsm06 https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1176/appi.books.9780890425596.dsm07 Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. • Chapter 9, Anxiety Disorders • Chapter 10, Obsessive-Compulsive and Related Disorders • Chapter 11, Trauma- and Stressor-Related Disorders • Chapter 31.11 Trauma-Stressor Related Disorders in Children • Chapter 31.13 Anxiety Disorders in Infancy, Childhood, and Adolescence • Chapter 31.14 Obsessive-Compulsive Disorder in Childhood and Adolescence INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide. In the Subjective section, provide: • Chief complaint • History of present illness (HPI) • Past psychiatric history • Medication trials and current medications • Psychotherapy or previous psychiatric diagnosis • Pertinent substance use, family psychiatric/substance use, social, and medical history • Allergies • ROS • Read rating descriptions to see the grading standards! In the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. • Read rating descriptions to see the grading standards! In the Assessment section, provide: • Results of the mental status examination, presented in paragraph form. • At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 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. • Read rating descriptions to see the grading standards! Reflect on this case. Include: Discuss what you learned and what you might do differently. Psychopathology And Diagnostic Reasoning paper
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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.). (The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) EXEMPLAR BEGINS HERE CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member. HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example: N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment. Or P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment. Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13. Caregivers are listed if applicable. Hospitalizations: How many hospitalizations? When and where was last hospitalization? Psychopathology And Diagnostic Reasoning paper
How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors? Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it) Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both. Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures. Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form. Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include: Where patient was born, who raised the patient Number of brothers/sisters (what order is the patient within siblings) Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children? Educational Level Hobbies: Work History: currently working/profession, disabled, unemployed, retired? Legal history: past hx, any current issues? Trauma history: Any childhood or adult history of trauma? Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical) Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries. Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products. Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance. Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination! You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Psychopathology And Diagnostic Reasoning paper
Always document in head-to-toe format i.e., General: Head: EENT: etc. Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). Assessment Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form. He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. Psychopathology And Diagnostic Reasoning paper
His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case. Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently? Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.). References (move to begin on next page) You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. Psychopathology And Diagnostic Reasoning paper
