Comprehensive Psychiatric Evaluation and information

Based on the following Comprehensive Psychiatric Evaluation and information provided, please complete the following:

• Diagnostic test/tool to be conducted or used and rationale.
• 3 differential diagnosis with one being a impulsive disorder or mood disorder with rationale.
• reflection of case (what could have been done differently)
• Case Formulation and Treatment plan

** case will be attached below** would not load properly to file

Subjective:

CC (chief complaint): per mother, patient was making statements about jumping off a balcony/out the window and reporting she wants to kill herself. Patient refused to participate in assessment and would not engage or answer any questions for this writer.

HPI: C.H is a 36-year-old Black female who presents from Sentara VA Beach General Hospital under a TDO for a psychiatric evaluation after acting out irrational and being exhibiting impulsive behaviors by sexually acting out inappropriately and making comments of wanting to self-harm. Patient presents with symptoms of mania and lack of concentration and unable to commit to safety or communicate needs currently. Patient was uncooperative with staff, up om their face and hostile with staff at times. Patient was non-verbal on assessment, but staff reports delusions of somatization and grandeur. The patient lacks orientation and lacks capacity and the patient is currently not aware of why she is in the hospital.

ROS:

General: unkept, well-nourished, well-developed, no fever, chills, or malaise, decrease sleep, denies pain

EENT: wears glasses, no blurred vision, no double vision, congestion, no difficulty swallowing

Respiratory: no shortness of breath, no chest pain, denies cough, no wheezing

Cardiovascular: denies chest pain. no palpitations, no swelling

Gastrointestinal: no N/V/D, no reflux, abdomen soft, non-distended

Genito-urinary: denies burning, frequency and urgency, no foul odor.

Neurological: headaches, no reports of seizures, no numbness or tingling

Endocrine: denies decrease in sensation

Musculoskeletal: no joint pain or swelling, steady gait, no falls, no deformities

Skin: no open lesions, no bruising, multiple tattoos

Mental health: no substance abuse, problems with memory, history of mania and impulsivity, depression, and anxiety

Past Psychiatric History:

·         General Statement: C.H is out of town and per records, has had multiple inpatient admissions since 2021 to current for schizophrenia, impulsivity, and mood disorder.

·         Caregivers (if applicable): patient lives with mother who reports much of history as patient lacks capacity.

·         Hospitalizations: this current hospitalization is first for current symptoms, patient has been treated on an outpatient basis

·         Medication trials:  patient is usually compliant with taking her medications but has left them home during this family vacation and reports she will not be taking once returning home. Patients’ medication includes Invega sustenna 117/0.75 mg once a month for schizophrenia D/O, Depakote 500 mg for Bipolar D/O (pt does not recall last dose taken) No side effects reported from either medication.

·         Psychotherapy or Previous Psychiatric Diagnosis:  Schizophrenia, Bipolar D./O, Borderline Personality D/O

Substance Current Use and History:  patient with no history of drug or alcohol abuse

Family Psychiatric/Substance Use History:  father committed suicide 7 years ago by way of gunshot, mother with anxiety and depression.

Psychosocial History:  patient currently lives with mother and younger sister. The patient was born and raised in North Carolina by both parents and comes from a physically abuse background. Patient is single with no children and currently receiving disability for her mental illness. Patient does not have many friends and spends majority of time with family.

Medical History:  migraines

·         Current Medications:  Invega sustenna IM 117/0.75 mg once monthly, Depakote DRT 500mg B.I.D, Topamax 50 mg T.I.D migraines, Trazodone 50 mg PRN nightly for sleep

·         Allergies:  ginger, chocolate, and no meats

• Reproductive Hx: none noted.

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:  C. H is a 36-year-old Black female presents as unkept with poor hygiene and took off her shirt with no undergarments during the assessment. No noted difficulties pertaining to patients’ motor skills. Patients’ behaviors were manic, distracted, and impulsive. She would not answer questions regarding orientation. When the client would decide to speak, speech was loud and a mood that altered between hostile and euphoric. Her affect was all overall incongruent. Unable to fully assess patients thought content, processing, memory, appetite and sleep due to lack of participation in the assessment. Patient was observed responding to auditory and visual hallucinations. She presents with no insight and impaired judgment currently.

Differential Diagnoses:

Reflections:

Case Formulation and Treatment Plan: