Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (Chief Complaint): “Everything in my life feels like it’s getting too much for me and I’m constantly worried about everything that is happening.”

HPI (History of Present Illness):

JM is a 32-year-old Caucasian male who presents today with a chief complaint of generalized anxiety. He reports that he has been excessively anxious for the past six months and that he has been worrying about every aspect of his life including, work, relationships, and health. This worry started six months ago and has made him virtually paralyzed as it pertains to his daily activities. JM describes the anxiety as difficult to control accompanied by feelings of restlessness, fatigue, and irritability. He finds it hard to fall asleep because of racing thoughts in his mind, and once he does, he frequently wakes up in the middle of the night. There has been no history of panic attacks or phobias. Current medications include over-the-counter sleep aids; thus further evaluation for possible treatment options are warranted.

Past Psychiatric History:

General Statement: His first contact with mental health services occurred at the age of eighteen when he sought counseling due to academic anxiety leading to panic attacks. He participated in psychotherapy for half a year where he mentioned that it helped him to some extent. Caregivers were not involved in this initial treatment.

Hospitalizations: There are no records indicating psychiatric hospitalizations, detox or residential treatment on behalf of this patient. No documented history suggests suicidal or homicidal behaviors while there have been no reported cases concerning self-harm.

Medication Trials: The patient had limited psychotropic medication trials previously. After taking sertraline for three months, there was some improvement in his anxiety symptoms although there were sexual side effects so he stopped taking them. No untoward side effects were recorded.

Psychotherapy or Previous Psychiatric Diagnosis: Previously he had cognitive-behavioral therapy which was moderately helpful according to him and he knows the specific type of psychotherapy which was done to him. The previous diagnosis from the initial treatment was anxiety disorder, NOS.

Substance Use History:

Caffeine: Reports daily consumption of two cups of coffee.

Nicotine: Denies current or past use of nicotine products.

Illicit substances: No history of illicit substance use.

Alcohol: Reports occasional social drinking, averaging two drinks per week. Last known use was two days ago. No history of withdrawal complications.

Family Psychiatric/Substance Use History: The patient’s family history reveals a maternal aunt diagnosed with generalized anxiety disorder. No history of substance use disorders or family suicides was reported.

Social History:

Born and raised by both parents in a suburban area.

One younger sister.

Currently lives with his partner in a committed relationship. They have no children.

Holds a bachelor’s degree in business administration.

Works as a project manager, currently facing increased stress at work.

Legal history: No past or current legal issues reported.

Trauma history: No documented history of childhood or adult trauma.

Violence Hx: No concerns or issues about safety reported.

Medical History: No significant illnesses or surgeries. No history of seizures or head injuries reported.

Current Medications:

Over-the-counter sleep aids on an as-needed basis.

Allergies:

No known allergies reported.

Reproductive Hx:

Menstrual history: Not applicable (male patient).

Pregnant/lactating: No.

Contraceptive use: Not applicable (male patient).

Types of intercourse: Not specified.

No current sexual concerns reported.

ROS:

GENERAL: The patient reports fatigue and decreased energy levels associated with anxiety. No fever, weight loss, or chills reported.

• HEENT (Head, Eyes, Ears, Nose, Throat): No history of headaches, vision changes, hearing loss, or nasal congestion. Denies any issues with the throat.

• SKIN: No rashes, itching, or significant skin abnormalities reported.

• CARDIOVASCULAR: Denies chest pain, palpitations, or edema. No history of hypertension or heart problems.

• RESPIRATORY: No shortness of breath, cough, or wheezing reported. No history of respiratory illnesses.

GASTROINTESTINAL: Reports some occasional stomach upset during times of increased anxiety. No significant changes in appetite, no nausea or vomiting.

• GENITOURINARY: There are no frequency, urgency, and changes in the habit of peeing. Did not complain about any pain in genital or urinary tract.

• NEUROLOGICAL: The patient has never had a seizure, tremor or head trauma. Headache is occasionally caused by stress.

• MUSCULOSKELETAL: No complaint about joint pains; stiffness and muscle weakness have not been also reported.

• HEMATOLOGIC: No bleeding disorders nor anemia have ever been recorded; reportedly.

• LYMPHATICS: No report on swollen glands or relevant history presented here.

• ENDOCRINOLOGIC: She has no record of thyroid dysfunction or diabetes mellitus. She does not feel excessive thirst nor hunger pangs.

Physical Exam:

General Appearance: The patient is well nourished and hydrated. He knows who he is, where he is, the year, month and day of the week. Vital signs include blood pressure 120/80 mmHg., heart rate 78 beats per minute respiratory rate 16 breaths per minute temperature 98.6°F. (37°C).

Skin: Skin warm and dry without rash, lesions or discoloration visible. Bruises or small red spots are absent

Head: Normal head with no tenderness or masses found within it; normal hair distribution

Eyes: Pupillary reaction to light is normal; extraocular movements preserved; conjunctiva clear without exudate; vision within normal limits

Ears: Ears even in size and shape without any anomalies; tympanic membranes intact without erythema or discharge; hearing appropriate to age

Nose: Tenderness absent over sinuses – nasal passages patent with no discharge nor bleeding observed

Throat: The oropharynx is clear with moist lips; the tonsils are not enlarged; no exudates or ulcers are noted.

Neck: The neck is flexible and has full range of motion. No enlargement of lymph nodes and thyroid glands were found. No noise was heard in carotid arteries.

Cardiovascular: Regular rate rhythm without any murmurs, gallops or rubs; peripheral pulses palatable and equal bilaterally. There is no edema of extremities.

Respiratory: Respiration regular, breath sounds clear bilaterally. There are no wheezes, crackles, or rhonchi. Respirations are even and unlabored.

Gastrointestinal: Soft abdomen with no tenderness or distention; bowel sounds present all quadrants; liver and spleen were not palpable

Genitourinary: CVAT absent; external genitalia were unremarkable. No urinary urgency or frequency

Neurological: Normal cranial nerves, strength and sensation within normal limits, symmetrical reflexes, alert and oriented to person place time. Focal neurological deficits were not observed.

Musculoskeletal: Full range of motion in all extremities; no visible joint swelling or deformity was noted; bilateral strength is grossly intact.

Psychiatric: Mood is anxious, affect is appropriate to content, and thought process is coherent. No perceptual disturbances or psychotic symptoms noted during the physical examination.

Diagnostic results:

CBC: Complete blood count

 A CBC may rule out anemia or infection, which may cause anxiety-like symptoms. Guidelines propose CBC testing to account for physiological aspects in psychiatric symptoms. The CBC reveals normal hemoglobin, hematocrit, white blood cell count, and platelet count, ruling out anemia or acute infection as causes of the patient’s symptoms (Wang et al., 2022).

Tests for thyroid function (TSH, Free T4):

Thyroid problems, especially hyperthyroidism, may resemble anxiety symptoms. Excess thyroid hormones may cause anxiety, restlessness, and irritability. Anxiety symptoms warrant thyroid function testing, according to the American Thyroid Association. Thyroid function tests show euthyroid function, ruling out thyroid malfunction as the patient’s anxiety reason (Kiel et al., 2020).

Assessment

Mental Status Examination:

Patient is a 32-year-old Caucasian man who looks his age. He is well dressed and helpful throughout the test. No psychomotor agitation or aberrant motor activity is noted. He speaks well and in a regular voice. The patient’s mental process is goal-oriented and rational, with no relaxation of connections or ideation.

Mood and affect are consistent, with the patient having an anxious mood and affect during examination. His acceptable facial expressions and smiles show some emotional fluctuation. Auditory and visual hallucinations are denied, and delusions are absent.

The patient reports a euthymic mood and has a suitable affect. He denies suicide or homicidal thoughts. Work, relationships, and health dominate thoughts in generalized anxiety disorder. Psychotic or delusional symptoms are absent.

Cognitively, the patient is aware of time, location, and people. His ability to recollect prior events and tell a cohesive account shows that his current and distant memories are intact. Symptoms of generalized anxiety disorder include racing thoughts that hinder concentration. He is honest about how anxiety affects his life.

In terms of judgment, the patient acknowledges the need for professional aid and is prepared to undergo anxiety testing and therapy. The mental status evaluation shows indications of generalized anxiety disorder, thus consultation with mental health experts is advised for a thorough treatment plan.

Primary Diagnosis:

Generalized Anxiety Disorder (GAD) – (F41.1)

Chronic and excessive anxiety about many life areas, restlessness, weariness, and difficulties focusing support the patient’s primary diagnosis of Generalized Anxiety Disorder (GAD). The patient satisfies DSM-5 criteria for GAD, which comprises excessive anxiety and concern for at least six months. Additionally, anxiety is hard to manage, affecting everyday life (Munir & Takov, 2022). The lack of symptoms resembling other main anxiety, mood, or adjustment disorders confirms GAD’s specificity. GAD is distinguished from other diseases by the chronicity and pervasiveness of concern, according to the research.

Differential Diagnoses:

Major Depressive Disorder (MDD)—296.22 (F32.9):

Pervasive concern, restlessness, and trouble focusing may indicate severe depressive illness, which commonly overlaps with GAD. However, the lack of chronic low mood, anhedonia, or despair and the dominance of anxiety make GAD a better first diagnosis (Bains & Abdijadid, 2023).

F41.0: Panic Disorder (PD)

Panic episodes, a hallmark of panic disorder, resemble patient symptoms. GAD is defined by persistent concern and generalized anxiety, whereas panic disorder is characterized by abrupt dread and physical symptoms. The lack of repeated, unexpected panic episodes with separate periods of severe terror in DSM-5 renders panic disorder less probable than GAD as the main diagnosis (Ziffra, 2021).

Adjustment Disorder with Anxiety (309.24) (F43.22):

Due to job stress and the patient’s increasing anxiety, adjustment disorder may be evaluated. In this situation, symptoms last longer and are more intense than in adjustment disorder. GAD is a better diagnosis owing to the patient’s constant anxiety and its effects on different aspects of life (Kelber et al., 2022).

Reflections:

Upon reviewing this case, I agree with the preceptor’s diagnosis of GAD. The patient’s presentation meets DSM-5 GAD criteria for persistent and pervasive concern, accompanying symptoms, and everyday functioning. The lack of other fundamental psychiatric disease symptoms confirms GAD’s specificity. This emphasizes the significance of rigorous exams that account both symptoms and absence when diagnosing.

I learnt the importance of differentiating between anxiety, depression and adjustment disorders from this single example. Appropriate diagnosis and treatment planning require knowledge about symptomatology and duration. The patient’s delayed assistance-seeking revealed to me the ignorance that people have about mental health care.

This case highlights the significance of a comprehensive psychiatric history especially when assessing potential risk factors for anxiety disorders in terms of legal and ethical issues. There may be need to address workplace stressors including his project manager position, heightened levels of stress as well as working with his employer towards making some adjustments due to this.

Mental health is influenced by social determinants of health. The patient’s nervousness is explained as a result of occupational pressure, socio-economic status, and cultural background. A holistic approach considering these factors is necessary for patient centered therapy and mental health.

Psycho-education on coping with stress, lifestyle modification, and building resilience should be integrated into health promotion and disease prevention programs. Culturally responsive treatments are more likely to be acceptable or incorporated when they are targeted according to the person’s age, ethnicity or culture.

Mental health and cultural beliefs behaviors would be my focus in future cases Working with occupational therapists to reduce job stress and improve coping skills may also be useful. In order to provide individualized culturally competent care that is comprehensive there is a need for constant learning and adaptation in the ever-changing field involving mental health treatment.

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

Bains, N., & Abdijadid, S. (2023, April 10).
Major Depressive Disorder. PubMed; StatPearls Publishing.

Kelber, M. S., Morgan, M. A., Beech, E. H., Smolenski, D. J., Bellanti, D., Galloway, L., Ojha, S., Otto, J. L., Wilson, A. L. G., Bush, N., & Belsher, B. E. (2022). Systematic review and meta-analysis of predictors of adjustment disorders in adults.
Journal of Affective Disorders,
304, 43–58.

Kiel, S., Ittermann, T., Völzke, H., Chenot, J.-F., & Angelow, A. (2020). Frequency of thyroid function tests and examinations in participants of a population-based study.
BMC Health Services Research,
20, 70.

Munir, S., & Takov, V. (2022, October 17).
Generalized anxiety disorder (GAD). National Library of Medicine; StatPearls Publishing.

Wang, Y., Li, X., Xu, J., & Zhou, Q. (2022). A complete blood count-based multivariate model for predicting the recovery of patients with moderate COVID-19: a retrospective study.
Scientific Reports,
12(1).

Ziffra, M. (2021). Panic disorder: A review of treatment options CORRESPONDENCE.
Annals of Clinical Psychiatry E22 ANNALS of CLINICAL PSYCHIATRY,
33(1), 22–31.