NRNP 6635 Week 7 Assignment: Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders
NRNP 6635 Week 7 Assignment: Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders
Assignment: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders
Psychotic disorders and schizophrenia are some of the most complicated and challenging diagnoses in the DSM. The symptoms of psychotic disorders may appear quite vivid in some patients; with others, symptoms may be barely observable. Additionally, symptoms may overlap among disorders. For example, specific symptoms, such as neurocognitive impairments, social problems, and illusions may exist in patients with schizophrenia but are also contributing to symptoms of other psychotic disorders.
For this Assignment, you will analyze a case study related to schizophrenia, another psychotic disorder, or a medication-induced movement disorder.
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To Prepare:
Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing psychotic disorders. Consider whether experiences of psychosis-related symptoms are always indicative of a diagnosis of schizophrenia. Think about alternative diagnoses for psychosis-related symptoms.
Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
By Day 7 of Week 7
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis.
Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis?
What is the duration and severity of their symptoms?
How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses?
Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority.
Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rule out the differential diagnosis to find an accurate diagnosis.
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 with this client if you could conduct the session over?
Also, include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!),
health promotion and disease prevention take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Rubric Detail
Name: NRNP_6635_Week7_Assignment_Rubric
Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
In the Subjective section, provide:
- Chief complaint
- History of present illness (HPI)
- Past psychiatric history
- Medication trials and current medications
- Psychotherapy or previous psychiatric diagnosis
- Pertinent substance use, family psychiatric/substance use, social, and medical history
- Allergies
- ROS–
Excellent 18 (18%) – 20 (20%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
In the Objective section, provide:
- Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
- Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.–
Excellent 18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
In the Assessment section, provide:
- Results of the mental status examination, presented in paragraph form.
- At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. 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.–
Excellent 23 (23%) – 25 (25%)
The response thoroughly and accurately documents the results of the mental status exam.
Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.
Reflect on this case.
Discuss what you learned and what you might do differently.
Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).–
Excellent 9 (9%) – 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical thinking.
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).–
Excellent 14 (14%) – 15 (15%)
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.
Written Expression and Formatting—Paragraph development and organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–
Excellent 5 (5%) – 5 (5%)
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and punctuation–
Excellent 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
Total Points: 100
Training Title 24
Name: Ms. Jess Davies
Gender: female
Age: 30 years old
T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs
Background: Jess is brought for evaluation by her 2 roommates who are concerned with
behaviors. She had some issues with depression after aunt died but worsened in the 12 days after
she witnessed her brother killed via GSW in a gas station burglary. She is estranged from her
parents and her brother was her only sibling. She is only sleeping 2 hours/24hrs; she will only eat
canned foods. She smokes cannabis daily since she was 17 and goes out on weekdays couple
times with her roommates and has couple drinks of beer. She was prescribed alprazolam 1mg
twice daily as needed by her PCP for 15 days. She works in a bakery. Allergies: medical tape
Symptom Media. (Producer). (2016). Training title 24 [Video
______________________________________________________________________________
TRANSCRIPT OF VIDEO FILE:
BEGIN TRANSCRIPT:
00:00:00
[sil.]
00:00:15
OFF CAMERA Your roommates, Rachel and Liz, shared some information with me. They said that you were fine, and that shortly after your aunt died, that you started acting in a different sort of strange way. Started having thoughts and hearing things that others couldn’t hear.
00:00:35
JESS- They think I’m living in a movie. Rachel and Liz. That’s who they think I am. I see a lot of movies. So maybe they’re right. Maybe I am a movie
00:00:45
OFF CAMERA I’m not sure I understand how you can be a movie.
00:00:45
JESS- Because they listen to our apartment.
00:00:50
[Whispers]
00:00:50
JESS- They listen from next door.
00:00:50
OFF CAMERA Who listens?
00:00:55
JESS- Russian men and whores. They drill all night long. That’s how they send their information back. Drilling.
00:01:05
OFF CAMERA Drilling. They send messages by drilling?
00:01:10
JESS- Doesn’t surprise me. Most people don’t understand.
00:01:15
OFF CAMERA Your roommates said that your favorite aunt that died, she’s the one who raised you.
00:01:20
JESS- Maybe she did. Maybe she didn’t. Who told you? Can you prove it? I can’t.
00:01:30
OFF CAMERA Liz and Rachel told me.
00:01:30
JESS- Good for them.
00:01:35
OFF CAMERA And your roommates said you had some new neighbors that moved in. Are these the neighbors you’re talking about?
00:01:45
JESS- They’re not neighbors. They’re Russians. They don’t answer their door. I tried to banging on their door and they didn’t answer. Figures. I mean they only speak English. They don’t speak English, they speak Russian in code.
00:02:00
OFF CAMERA You know, your roommate, Rachel, told me your new neighbors speak Spanish. They speak Spanish.
00:02:10
JESS -They lie. But what do you expect?
00:02:15
OFF CAMERA What do they do? Your neighbors?
00:02:20
JESS- I don’t want to talk about this any more.
00:02:25
OFF CAMERA You know, Jess, I imagine what you are experiencing right now feels very frightening. I hear from a lot of the people who, hear voices that maybe aren’t there, that it’s very frightening. And it’s upsetting. Are you experiencing anything like that?
00:02:40
JESS- Yes. I hear them talking when no one else can. I mean not Rachel, not Liz. That’s why I went down to my car yesterday. Because if I’m very, very still, the Russians can’t code me.
00:02:55
OFF CAMERA What do you mean code you?
00:03:00
JESS- You know. You act like you don’t know, but you know.
00:03:05
OFF CAMERA How long did you stay in your car?
00:03:10
JESS- Six hours. I watched them move in and out.
00:03:15
OFF CAMERA So do you sometimes see things that your roommates don’t see?
00:03:20
JESS- No. But I know things that they don’t know.
00:03:30
OFF CAMERA Jess, I realize it is difficult sometimes for people to tell me things but it really helps me with their background. Has anything happened recently? Anything traumatic?
00:03:40
JESS- I think that secret government papers are traumatic. Like blueprints. I mean, they have blueprints of buildings. My apartment is a building.
00:03:55
OFF CAMERA What are the blueprints?
00:03:55
JESS- They’re all over the walls. That’s what they want.
00:04:00
OFF CAMERA The neighbors?
00:04:00
JESS- The Russians. They’re terrorists. You’ll find out too late.
00:04:10
OFF CAMERA Has anyone else seen these blueprints Jess?
00:04:10
JESS- I can stop them from seeing them. I covered the walls, I marked up the walls. I just need more markers.
00:04:20
OFF CAMERA Jess, do you drink alcohol or take drugs?
00:04:25
JESS- My body is my temple. No.
00:04:30
OFF CAMERA Have you been taking any prescription medications?
00:04:35
JESS- Yes I did. I was.
00:04:40
OFF CAMERA So you stopped taking your medications?
00:04:45
JESS- Yes I stopped taking my medications. The medications were part of the problem. But you know all about that, don’t you?
00:04:55
OFF CAMERA Jess, do you have any thoughts of hurting yourself, or hurting any other people?
00:05:00
JESS: Rachel and Lizzy? I don’t think they’re in on it. Time will tell.
00:05:10
[sil.]
00:05:10
END TRANSCRIPT
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
- Chief complaint
- History of present illness (HPI)
- Past psychiatric history
- Medication trials and current medications
- Psychotherapy or previous psychiatric diagnosis
- Pertinent substance use, family psychiatric/substance use, social, and medical history
- Allergies
- ROS
- Read rating descriptions to see the grading standards!
In the Objective section, provide:
- Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
- Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
- Read rating descriptions to see the grading standards!
In the Assessment section, provide:
- Results of the mental status examination, presented in paragraph form.
- At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. 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.
- Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.
Or
P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5-TR diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.
Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:
Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within siblings)
Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
Educational Level
Hobbies:
Work History: currently working/profession, disabled, unemployed, retired?
Legal history: past hx, any current issues?
Trauma history: Any childhood or adult history of trauma?
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)
Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Assessment
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnostic impression selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
A Sample Of This Assignment Written By One Of Our Top-rated Writers
NRNP 6635 Week 7: Assignment: Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders
CC (chief complaint): “My roommates think I’m living in a movie.”
HPI:
Jess Davies is a 30-year-old female brought for psychiatric evaluation by her two roommates (Rachel and Liz), who are worried about her behavior. Jess states that her roommates think she is living in a movie and that she is actually a movie because she watches many of them. According to Jess’ roommates, she was fine until after the death of her aunt who raised her. She developed depressive symptoms, which worsened 12 days after witnessing her brother murdered by a gunshot in a gas station burglary. She then began having thoughts and hearing inexistent things. Jess mentions that there are Russians next door who spy on them and send information by drilling. She states that the new neighbors are Russians who communicate in a Russian code. On the other hand, her roommates state that they speak Spanish, but Jess insists they are lying. She reports that she hears the ‘Russian neighbors’ talk while her roommates cannot. As a result, she went to stay in the car last evening and remained still for six hours because the Russians cannot code here. She denies seeing things that her roommates cannot see, but she is aware of things they do not. Furthermore, she states that the Russian neighbors are terrorists since they have blueprints of their building. As a result, she covered and marked up the walls to stop the Russians from seeing them.
Past Psychiatric History:
- General Statement: The client first presented for psychiatric evaluation due to depression after her aunt died.
- Caregivers (if applicable): None
- Hospitalizations: None
- Medication trials: She was prescribed Alprazolam 1mg BD but stopped taking them.
- Psychotherapy or Previous Psychiatric Diagnosis: Depression.
Substance Current Use and History: History of cannabis use since she was 17. She takes a couple of beers on weekends.
Family Psychiatric/Substance Use History: No history of psychiatric disorders or SUD in the family.
Psychosocial History: Jess works in a bakery and lives with her roommates, Rachel and Liz. She was raised by her aunt after being separated from her parents and had only one sibling, her brother.
Medical History:
- Current Medications: Alprazolam 1mg BD for 15 days.
- Allergies: Allergic to medical tape
- Reproductive Hx: None.
ROS:
- GENERAL: Denies fever, chills, appetite or weight changes, or low energy levels.
- HEENT: Negative for headache, eye pain, double/blurred vision, ear pain, hearing loss, rhinorrhea, or pain when swallowing.
- SKIN: Negative for color changes, bruises, rashes, or itching.
- CARDIOVASCULAR: Negative for palpitations, edema, chest pain, or SOB on exertion.
- RESPIRATORY: Negative for cough, sputum, wheezing, or SOB.
- GASTROINTESTINAL: Negative for anorexia, vomiting, abdominal pain, or constipation/diarrhea.
- GENITOURINARY: Negative for pelvic pain, dysuria, or incontinence.
- NEUROLOGICAL: Negative for headache, syncope, muscle weakness, or numbness.
- MUSCULOSKELETAL: Denies muscle pain, joint stiffness/pain, or back pain.
- HEMATOLOGIC: Negative for bruising or bleeding.
- LYMPHATICS: Negative for enlarged lymph nodes.
- ENDOCRINOLOGIC: Denies increased hunger, thirst, or urination.
Physical exam: if applicable
T- 98.6, P- 86, R-20, BP-120/70, Ht-5’2, Wt-126lbs
Diagnostic results: No tests were ordered.
Assessment
Mental Status Examination:
A female client in her 30s sits still, is alert, and appears anxious. She is well-groomed but wears a winter coat on a sunny day. She avoids eye contact and constantly fidgets on the chair. Her self-reported mood is worried, and her affect is broad. Her speech is clear, but the rate varies from normal to low. She has a coherent and logical thought process. Auditory hallucinations and persecutory delusions are evident. She denies having suicidal or homicidal thoughts/ideas. The client is oriented to person, place, and time. Her memory is intact, and she exhibits sound judgment. Insight is absent.
Differential Diagnoses:
Brief Psychotic Disorder: This is a form of psychotic disorder belonging to the same class as the schizophrenia spectrum. The DSM-V diagnostic criteria for Brief Psychotic Disorder require a sudden onset of at least one of the following: delusions, hallucinations, disorganized speech, and catatonic behavior (APA, 2013). The difference between Brief Psychotic Disorder and schizophrenia is primarily its sudden onset and short duration (less than a month) in which a patient returns to complete functioning (Fusar-Poli et al., 2022). Brief Psychotic Disorder is the presumptive diagnosis owing to the patient’s abrupt onset of auditory hallucinations and persecutory delusions, which have lasted less than a month (12 days).
Schizophrenia: Schizophrenia is a psychotic condition that manifests with cognitive, behavioral, and emotional symptoms (Stępnicki et al., 2018). The DSM V diagnostic criteria require at least two of the following psychotic features present for one month: Hallucinations, delusions, disorganized or catatonic behavior, disorganized speech, and negative symptoms (APA, 2013). Schizophrenia is a differential diagnosis based on the patient’s psychotic features of auditory hallucinations and persecutory delusions. However, the symptoms have not been present for at least one month, making schizophrenia an unlikely primary diagnosis.
Substance-induced psychotic disorder (SIPD): The DSM-V outlines that SIPD is characterized by delusions and hallucinations associated with the physiological effects of a substance or medication (APA, 2013). This is based on evidence from a patient’s history, physical examination, or laboratory findings. SIPD can manifest with the full range of psychotic symptoms, including delusions, hallucinations, impaired cognition, psychomotor changes, disorganized speech, and mania (Gicas et al., 2022). SIPD is a differential diagnosis due to the patient’s auditory hallucinations and persecutory delusions, which her long history of cannabis use could have caused. However, the patient has no history or physical exam findings linking the psychotic feature to cannabis use, ruling out SIPD as a primary diagnosis.
Reflections:
From this assignment, I have learned to differentiate the different conditions that present with psychotic symptoms: Brief Psychotic Disorder, Schizophrenia, and SIPD. I have learned that the sudden onset of Brief Psychotic Disorder refers to a change from a non-psychotic state to an evident psychotic state within two weeks, and patients usually have no prodrome. In a different situation, I would utilize assessment tools like the Brief Psychiatric Rating Scale (BPRS) to assess the severity of the patient’s psychotic symptoms (Seiler et al., 2020). The PMHNP has an ethical duty to ensure the patient receives treatment based on best practices to promote the best possible outcomes while ensuring safety. Access to healthcare is an SDOH that may impact the patient’s outcomes. Limited access to mental health care may worsen the patient’s condition and lack of access to medication (Alegría et al., 2018). Health promotion and patient education should focus on educating the patient about her condition and encouraging healthy lifestyle practices.
References
Alegría, M., NeMoyer, A., Falgàs Bagué, I., Wang, Y., & Alvarez, K. (2018). Social Determinants of Mental Health: Where We Are and Where We Need to Go. Current Psychiatry Reports, 20(11), 95. https://doi.org/10.1007/s11920-018-0969-9
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
Gicas, K. M., Parmar, P. K., Fabiano, G. F., & Mashhadi, F. (2022). Substance-induced psychosis and cognitive functioning: A systematic review. Psychiatry Research, 308, 114361. https://doi.org/10.1016/j.psychres.2021.114361
Fusar-Poli, P., Salazar de Pablo, G., Rajkumar, R. P., López-Díaz, Á., Malhotra, S., Heckers, S., Lawrie, S. M., & Pillmann, F. (2022). Diagnosis, prognosis, and treatment of brief psychotic episodes: a review and research agenda. The Lancet. Psychiatry, 9(1), 72–83. https://doi.org/10.1016/S2215-0366(21)00121-8
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