Comprehensive psychiatric evaluation

Comprehensive psychiatric evaluation

Student’s name

Course title

Institution

Instructor’s name

Date

Introduction

This is a case analysis for jenny a 28-year-old female accompanied by her boyfriend at the outpatient department. She reports of memory loss, impaired concentration, lightheadedness, and feels fatigued. She denies a history of head injury, no military services, and ongoing legal issues in her past medical history. On general Examination, she looks distraught, disassociated, and tearful. Professionally, she is a teacher working at an elementary school teaching first and second graders. She reports having grown up in middle-class suburbs outside Chicago, Illinois, with her two younger brothers’ elder sister. She denies using drugs and reports to have been avoiding alcohol due to previous bad experiences. In her family history, the father had alcohol use disorder and PSTD. Her mother is on the treatment of a disease; she thinks it could be bipolar.

Subjective Data

Chief Complaint: lightheadedness, fatigue, and impaired memory and concentration.

History Of The Presenting Illness

the patient reports of lightheadedness that was the acute onset and recurred often. It was associated with impaired memory and difficulties in concentration. She reports having the feeling of tired. She reports having episodes of sleep disturbances, though not every day. She reports of a shift in feeding habits; at times, she has hugely increased appetite, and at the time, she does not feed at all. No history of tinnitus, no history of blurring of vision. The patient denies a history of head trauma. She has not been on any medication.

Past Medical And Surgical History

Jenny has no past medical experiences. She has never been admitted in a hospital, never had a blood transfusion, never undergone any surgical procedure. She is not on any medication currently. However, there is no known history of food and drug allergy.

Personal, Social-Economic And Family History

Jenny is a 28- years old female who is a teacher by profession. She is in a relationship with Zack. She does not use drugs but has a positive history of alcohol use but stopped due to bad experiences. She has two younger brothers and one elder sister. Her father suffers from PSTD and alcoholic disorder. Her mother is known to have bipolar, and she is on treatment.

Obstetrics And Gynecology History

Her menarche was at the age of 14 years. She reports having a regular 28-days cycle, for three days, normal flow with no history of dysmenorrhea. She reports of engaging in regular vaginal sexual intercourse. She has no child and does not use any form of family planning.

Review Of Systems

The affected system is the nervous system. It presents with lightheadedness, fatigue, impaired memory and difficulties in concentration. However, there are no episodes of headache, fainting, and convulsions. The cardiovascular, genital-urinary, respiratory, gastrointestinal, and muscular-skeletal systems are not affected. However, the patient does not report any history of chills and rigours, body weakness, and weight loss.

Objective Data

General Examination: the patient is in a general fair condition and clinically afebrile. However, she has no pallor, jaundice, oedema, dehydration, lymphadenopathy, and cyanosis. Her vitals are within the standard reference. Her blood pressure at 120/78 mmHg, the pulse is at 88 beats per minute, the temperature at 36.4 degrees celsius.

Systemic Examination: no significant finding in all the systems.

Diagnostic Tests: Laboratory investigations are essential to rule out the cause of the ailment and diagnose. A complete blood count checks the white blood cells, red blood cells, and platelets. The levels of white blood cells rule out infections that may cause lightheadedness and confusion. Low haemoglobin causes anaemia that presents with lightheadedness and fatigue. Thyroid function tests show the level of T3, T4, and thyroid-stimulating hormone. These are the determinants of hypothyroidism and hyperthyroidism. Hyperthyroidism presents with depressive moods. Urea, creatinine, and electrolytes test are helpful to determine the cause of the depressive moods. Deranged kidney function test presents with impaired memory and easy fatigability. Other tests are arterial blood gas analysis, liver function tests, blood and urine toxicology screen.

Assessment

Mental Status Assessment: she is a 28-year-old female who is cooperative with the clinician. She appears to be well-groomed, clean and dressed appropriately. She has regular mortal activity. She is distraughtly disconnected and tearful. Her speech is shaky not very clear but with a normal tone and volume. Her mood is sad and affects appropriate to the mood. She does not experience any visual or auditory hallucinations. There is delusional thinking observed. She has no suicidal ideation. She is disconnected with impaired memory and difficulties in concentrating. Her insight is useful.

Differential Diagnosis

In this case scenario, the differentials are generalized depression, anxiety disorder, and bipolar. DSM-5 means statistical diagnostic manual for mental disorders. It has descriptions and symptoms that act as a guide to diagnosing mental disorders (Hasin et al., 2020). Depression DSM-5 criteria symptoms are either depressed mood or loss of interest or pleasure. This patient presents with loss of interest or pleasure and depressed mood 9 Gold, et al., 2020). She has lightheadedness, impaired memory, feeling exhausted, and difficulties in concentrating. DSM-5 criteria for generalized anxiety disorder present with excessive anxiety and worry, impaired concentration, irritability, difficulty sleeping, restlessness, and fatigue (Strawn et al., 2020). DSM-5 criteria for bipolar disorder present with depressed mood, loss of interest, increased appetite or weight loss, sleep disturbances, psychomotor changes such as agitation and retardation, fatigue and tiredness, impaired ability to think, concentrate, or make decisions (Carvalho et al., 2020). The actual diagnosis for this patient is a generalized anxiety disorder. She is anxious about buying a car, and she is anxious about talking about violence. She has lightheadedness of acute onset and was not associated with trauma. She has impaired concentration and loss of memory, she feels fatigued, and she is emotional during the assessment.

Reflection note

Having another opportunity with jenny would lead me to start psychotherapy sessions. It is oriented towards combating the individual’s low level, ever-present anxiety, and developing healthy thinking patterns. Psychotherapy sessions help the patient reduce the anxiety levels engaging in relaxation skills, exercises, and overall stress coping skills. When initiating this treatment modality, the healthcare professional should consider ethical principles such as respect for autonomy, informed consent, beneficence, and non-maleficence (Carr, 2020). Since jenny cannot make a conscious health decision, the care provider should have the best interest to provide useful and quality healthcare services. The care practitioner should ensure patient safety and consider the patients’ preferences and needs before initiating the sessions. The healthcare provider should seek informed consent from the patient before initiating treatment. Since the patient has a positive family history of mental illness, she should be on the regular mental assessment.

 

 

 

References

 

Carr, S. (2020). ‘AI gone mental’: engagement and ethics in data-driven technology for mental health.

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66.

Gold, S. M., Köhler-Forsberg, O., Moss-Morris, R., Mehnert, A., Miranda, J. J., Bullinger, M., … & Otte, C. (2020). Comorbid depression in medical diseases. Nature Reviews Disease Primers, 6(1), 1-22.

Hasin, D., Shmulewitz, D., Stohl, M., Greenstein, E., Roncone, S., Aharonovich, E., & Wall, M. (2020). Test-retest reliability of DSM-5 substance disorder measures as assessed with the PRISM-5, a clinician-administered diagnostic interview: drug and alcohol dependence, 216, 108294.

Strawn, J. R., Mills, J. A., Schroeder, H., Mossman, S. A., Varney, S. T., Ramsey, L. B., … & DelBello, M. P. (2020). Escitalopram in Adolescents With Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled Study. The Journal of Clinical Psychiatry, 81(5), 0-0.