Comprehensive Psychiatric Assessment and Patient Case Presentation
Chief Complaint
I don’t have to give my name, people are after me, and I have to be careful.”
V.O. is a 35-year-old African American female who presented to ED with erratic and bizarre behavior. Patient was brought in because she was walking in and out of traffic, not answering appropriately to police queries, yelling, screaming, and singing, refusing to tell her name, paranoid and delusional. During assessment patient furnishes delayed responses to queries, aloof and oblivious, to events going on around her, detached and internally preoccupied; responding to internal stimuli, impaired clarity of thought, disrupted train of thought, distracted and disorganized thought and behavior, suspicious, distrustful, and hypervigilant. (UDS is positive for THC, cocaine, methadone and ETOH level 84 and medication non-compliance. No drug/food allergies reported. No family history of psychiatric reported. Denies having suicidal/homicidal ideations denies feeling depressed and denies auditory hallucinations. Denies history of suicidal attempts.
Vital sign: BP 131/65, P 74, R 16, T 97.5, SPO2 98%RA, Weight 149lbs
PAST PSYCHIATRIC HISTORY
Schizoaffective disorder bipolar type.
Patient has had multiple psychiatric hospitalizations in different hospitals
PAST MEDICAL HISTORY
Asthma
PERSONAL/SOCIAL HISTORY
Patient reports being single, never married, have 2 children that live with their father, homeless, unemployed, and receive monthly SSI. HCG negative, UDS positive for THC, cocaine, methadone and ETOH level 84. Denies owning any firearms and denies any legal history.
MENTAL STATUS EXAMINATION:
Patient is alert and oriented to person and situation.
Appearance: Disheveled, Unkempt
Attitude: Anxious, distrustful, guarded, impulsive, suspicious Normal developed
Posture: rigid
Eye contact: downcast
Expression: blank
Speech: delayed, incoherent, minimal
Insight: poor
Judgment: poor
Affect: Irritable, labile
Mood Irritable
Attention: distracted, poor attention
Memory immediate: intact
Memory recent past: intact
Memory remote past: intact
Thought process: flight of ideas, loose association, tangentiality, and withdrawal
Thought content: delusions
Perceptual Disturbance: hallucinations
Medications:
Risperdal 2 mg PO QHS for psychosis
Depakote ER 500 mg PO Q daily for mood
Ativan 2 mg IM q 4 hrs. PRN for anxiety
Haldol 5 mg IM q hrs. PRN for agitation
Benadryl 50 mg IM Q 6 hrs. PRN for EPS
Ambien 10 mg PO QHS PRN for insomnia
Flovent 220 mcg inhalers administer 2 puffs q 12 hrs. for SOB/Wheezing.
Diagnosis
Paranoid schizophrenia
Polysubstance abuse
PLEASE ADD ONE MORE DIAGNOSIS TO MAKE IT 3 BASED ON THE CASE STUDY.
· 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?
· Reflection notes: What would you do differently in a similar patient Assessment?
PLEASE ADD ONE MORE DIAGNOSIS TO MAKE IT 3 BASED ON THE CASE STUDY.
· Include at least five (5) scholarly resources to support the assessment and diagnostic reasoning.
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Patient Case Presentation and Comprehensive Psychiatric Assessment
The Main Complaint
I don’t have to provide my name since people are looking for me and I need to be cautious.”
V.O. is a 35-year-old African-American woman who arrived to the emergency department with unpredictable and odd behavior. The patient was brought in because she was walking in and out of traffic, not responding adequately to police questions, yelling, screaming, and singing, refusing to reveal her name, and was paranoid and delusional. During the assessment, the patient appears aloof and inattentive to events around her, disconnected and internally preoccupied; responding to internal stimuli, impaired clarity of mind, disrupted stream of thought, distracted and disorganized thought and conduct, suspicious, distrustful, and hypervigilant. (UDS detects THC, cocaine, methadone, and ETOH.)
