Comprehensive Psychiatric Evaluation and Patient Case Presentation
Case History Reports:
Patient is a 61-year-old widowed A/A/male who is employed at Children Hospital as security officer. Vital: T- 98.7, P- 77, R 23 146/84 Ht 5â€
6 Wt 180lbs. Born and raised in Maryland. Patient was referred by PCP for evaluation and treatment of depression. Patient states that “I feel sad, depressed, unable to sleep, and lose weight, hard to focus and concentrateâ€. for the last 2 weeks I am not myself. I feels very sad other day about a week ago i was at my PCP office, I just broke down completely for no reason. PCP started me on Zoloft 25 mg daily. Depressive symptoms, pt describe that he feels sad all the time. low energy, low motivation, do not enjoy things used to enjoy before, get hopelessness feelings, though denied S/I. Patient has no hx of psychiatric illness in past, he was in normal mental health till about 2 weeks ago when his wife of 28 years together passed away. She was doing well till about 1 month ago. Patient died of colon cancer – stage 4 she was in remission for more than 2 years.
Claims he has support from family but he lives by self. Patient states that he loss appetite loosed about 15 lbs. in 2 weeks. He has difficulties in falling and staying sleep/crying spells. Patient feels anxious, nervous and thinking about wife missing her a lot, no anxiety attack, no panic attack, no hx of mood swings no mania, no OCD. Denied a/h no delusion, denied ETOH and drug abuse. patient well nourished, well hydrated, APPEAR SAD DEPRESSED; +well dressed; Claims he is unable to go to work for the last 2 week. Patient works in hospital where he sees death often and that would remind him about his wife. He feels he is not able to handle work stress seeing people losing love ones. Patient drinks about 4 beers a day just to be able to sleep. Prior out patient alcohol/substance abuse treatment? No, Prior outpatient treatment was helpful? No, Number of prior psychiatric hospitalizations: 0, Date of last psychiatric hospitalization: 0, Number of prior alcohol or substance abuse hospitalizations: 0, Aggression towards: 0, Substance Use History, Cannabinoids: (marijuana, hashish) ? No, Opioids and Morphine Derivatives: (codiene, morphine, Heroin, opium)? No, Intravenous drug use ? No, Did your biological parents separate or divorce during your childhood? Yes. Allergies Reported by Patient: Bactrim, Amoxicillin. Sexual abuse: No, Education Highest Grade: Grade 12, Number of children: 1 SON WHO IS 42 YR OLD
PRESCRIPTIONS
Remeron 15 mg tablet, Take 1 tablet(s) by oral route, qhs times per day
Xanax 0.5 mg tablet, Take 1 tablet(s) by oral route, qhs prn times per day
Assignment Instructions:
1. Review the additional data for the case in the “Case History Reports†document, keeping the requirements of the evaluation template in mind.
2. Consider what history would be necessary to collect from this patient.
3. Consider what interview questions you would need to ask this patient.
Be succinct in your presentation, Address the following:
• 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?
• 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? 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 in a similar patient evaluation? Also, 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.).
NRNP-PRAC+6635+Comprehensive+Psychiatric+Evaluation-PRESENTATION+Template (1) PRAC+PRESENTATION+Assignment+Instructions+NDUNG (1) NRNP-PRAC+6635+Comprehensive+Psychiatric+Evaluation-PRESENT+Exemplar (1) NRNP-PRAC+6635+Comprehensive+Psychiatric+Evaluation-PRESENT+Exemplar NRNP-PRAC+6635+Comprehensive+Psychiatric+Evaluation-PRESENTATION+Template PRAC+PRESENTATION+Assignment+Instructions+NDUNG
APA
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