Comprehensive Psychiatric Evaluation

Answer

Week (enter week #): Comprehensive Psychiatric Assessment

Subjective:

CC (chief complaint): Indecent exposure and insomnia.

HPI: Mr. Will Loman, a 19-year-old male, has a pending court date for indecent exposure. He does not have any partner at the moment. He is reported to have been sexually inappropriate with comments towards female neighbors and he once pulled down his pants in the mall. In addition, his mother reports that Loman has been sleeping for 2 to 3 hours in the past week and spending most time purchasing and playing new video games. He claims that he is writing a book to guide other people on how to become video game masters.

Past Psychiatric History:

• General Statement: At the age of 15, Loman was diagnosed and treated for mood disorder. He has no history of trespassing as a juvenile or self-harm. He is alert and oriented in all spheres. He appears appropriately dressed and in no acute psychological distress.
• Caregivers (if applicable): Loman’s mother is concerned that he has not had enough sleep in the past week, sleeping only 2 to 3 hours per day.
• Hospitalizations: Two years ago, he was found wandering on the side of the freeway. As a result, he was hospitalized from three days. At this time, he refused medications citing previous experiences. At the third day of hospitalization, he signed himself out against medical advice.
• Medication trials: At 15 years of age, Loman was prescribed Depakote and olanzepine off and on, for management of a mood disorder. Weight gain was then reported as a side effect associated with olanzepine use.
• Psychotherapy or Previous Psychiatric Diagnosis: Mood disorder.

Substance Current Use and History: Denies any recent alcohol or substance use. The patient should be asked whether he has used alcohol, smoked cigarettes or use illicit substances in the past.

Family Psychiatric/Substance Use History: No family history of suicides. Father has history of bipolar disorder. It should be established whether there is family history of anxiety, mood disorders or depression. Loman’s sister is in need of a psychiatric and psychosocial assessment since Loman states that his sister cannot remember anything and she seems confused. Lowan claims that he has witnessed her putting the radio in the refrigerator and the cat in the microwave oven, which is a matter of concern.

Psychosocial History: The patient is not currently partnered. More needs to be known on whether her has friends or participates in social circles. Does he have competent language and/or social skills? Can he make and maintain new friendships?

Medical History: There is no medical history. History of chronic conditions need to be established. 

• Current Medications: No current medications. He should be counseled about the usefulness of medications for managing his condition and be informed about the benefits and side effects of any prescribed medication in the future.
• Allergies: The patient is allergic to penicillin.
• Reproductive Hx: He does not have any partner currently. His sexual orientation ought to be established? Does he have sexual fantasies?

ROS:

• GENERAL: The patient is oriented to person, place, and time. His is calm interactive and maintains fair eye contact.
• HEENT: H: normocephalic. No jugular vein distension,
• SKIN: The skin is supple without any visible cuts or wounds on the exposed areas.
• CARDIOVASCULAR: S1 and S2 need to be assessed and established whether there is S3 and/or S4. Murmurs need to be assessed.
• RESPIRATORY: No wheezing or difficulty in breathing. It should be established whether the lungs are clear to auscultation.
• GASTROINTESTINAL: He reports loss of appetite. He should be asked whether he has symptoms of diarrhea, vomiting, diarrhea or abdominal pain.
• GENITOURINARY: He should be asked about frequency, volume, urgency, color, smell of urine, and/or pain during urination.
• NEUROLOGICAL: He should be asked about loss of sensations or uncontrolled muscle movement.
• MUSCULOSKELETAL: The patient should be asked about history of muscle and/or joint pain and be assessed for range of motion in all extremities.
• HEMATOLOGIC: He should be asked whether he has any blood disorder such as bleeding disorders.
• LYMPHATICS: His lymph nodes need to be assessed on whether they are tender or inflamed.
• ENDOCRINOLOGIC: He should be asked he has any problem in controlling his body temperature.

Objective:

Vital Signs: T- 98.6 P- 94 R 24 128/78 Ht 5’7 Wt 152lbs.

Physical exam: if applicable

Diagnostic results: The patient presents with mild delusions and hallucinations, but the thought processes remain fairly logical.

Assessment:

Mental Status Examination:

            Mr. Will Loman is a 19-year-old male who appears appropriately dressed, calm with not acute psychological distress. He does not present with any sign of agitation, restlessness or aggression during the interview. His affect is labile, but it appears that it is appropriate to the content and context of his speech, since he is concerned about his sister undergoing another CT scan. He believes that the previous CT scan in which his sister underwent was the reason that made her to present with memory and behavioral issues. His speech is audible, elaborate and systematic but he is overelaborative in his speech. During the interview, he seemed to exhibit flight of ideas and loosening of associations; he unpredictably and intermittently shifted the topic of conversion from giving suggestions about what he thought should be done for his sister to asking whether the room had one way cameras and stating that he always take precautions from the Russian infrared rays at home since he does not want to be sterile or have leukemia. The general overview is that he is acting in a way to protect his sister from perceived harm that can be experienced from the healthcare setting. Loman presents with signs of hallucinations since he perceives the presence of Russian infrared rays is intended to sterilize people or cause leukemia. Lowan’s mother describes his grandiose delusions that he is writing a book on how to guide others make video games. This is not the reality since he has just completed high school with no knowledge and skills to make video games but just an obsession with video games. He is oriented to person, place and time, but seem to ask whether he is in a one-way camera room or whether the interviewer is Devita Honeysuckle. He does not have homicidal or suicidal ideation. He needs to be examined for memory-related and intellectual-related portions of the examination. However, his memory seems intact given than he can remember names of some doctors and some of the questions in which his sister was asked by the doctors in the previous visit. Judgement and insight should also be evaluated. He focused so much on his sister and for this reason he should be assessed on whether he acknowledges that he has psychiatric symptoms. His judgement seems impaired since he believes that a CT scan made his sister to experience memory and behavioral issues (Voss & Das, 2020).

Differential Diagnoses:

1. Schizophrenia, paranoid type: The Diagnostic and Statistical Manual for Mental Disorders (5^th ed) [DSM-5] state that schizophrenia, paranoid type diagnosis, is made if a patient has two or more symptoms (delusions, hallucinations, catatonic behavior, disorganized speech and/or negative symptoms) for at least 1-month period (American Psychiatric Association [APA], 2013). Loman presents with hallucination and delusion for more than 1 month; therefore, this is the final presumptive diagnosis.
2. Major depressive episode: DSM-5 guides that this diagnosis is made when there is five or more of the following symptoms; depressed mood, anhedonia, weight changes, sleep disturbances, tiredness, psychomotor changes, sense of worthlessness, impaired ability to think, and/or recurrent thoughts (APA, 2013). However, Loman only presents with sleep problems, and an impaired ability to think, therefore, ruling-out this differential diagnosis.
3. Schizoaffective disorder: DSM-5 state that two or more of the following symptoms such as delusions, hallucinations, negative symptoms, grossly disorganized symptoms, and/or disorganized speech (APA, 2013). In addition, hallucinations and delusions should not be associated with major mood episodes; however, Loman has history of mood disorders therefore, this disorder is ruled-out in favor of schizophrenia, paranoid type (Wy & Saadabi, 2021).

Reflections: If I could have been in the position of the interviewer, I could have focused on my client rather than her sister. The whole interview centers around the client’s sister and gives little information about the client himself. In terms of legal and ethical consideration, I could have encouraged the client to give an honest answer on whether he had ever used illicit drugs with the promise that I would not disclose his information to law enforcement authorities. Loman needs close attention and follow-up given that he has history of mood disorders with the potential current diagnosis of schizophrenia, paranoid type. It is also evident that Loman is in need of social support; thus, there is need to take him out of his room into social circles. I would advice his parents to enroll him in college to help him interact with his peers. This would help to improve treatment outcomes.