Posted: October 6th, 2022

Comprehensive Psychiatric Assessment Note and Patient Case Presentation

Week four: Comprehensive Psychiatric Assessment Note and Patient Case Presentation

School of Nursing-PMHNP, Walden College
NRNP 6645: Psychotherapy with A number of Modalities

Week four: Comprehensive Psychiatric Assessment Note and Patient Case Presentation
Patient Initials: ___Edwin____ Age: ___24____ Gender: ___M____ Ethnic group: Hispanic
Subjective:
CC (chief criticism): “ I really feel trapped; I really feel like I can’t escape my melancholy; it appears to convey me again to feeling down and caught. I really feel like I get testy with folks, and my anger is regularly rising inside me, constructed up anger inflicting my melancholy; little issues get me indignant equivalent to strangers when folks converse rudely to me. I get caught with the emotion and can’t act out. My anger is inflicting me to have anxiousness; it’s regularly rising. COVID has made me really feel like one thing is incorrect; if I really feel down, I’ll by no means get my life again; I really feel trapped. I really feel insecure. I really feel like a foul pal, and I really feel like they’re avoiding me. I’m wondering the place did I am going incorrect? My melancholy has made me really feel like I hit a bumper and that I brought on my melancholy. My mates and household who know me know that I’m compassionate and humorous. I’m afraid that I’m going to be annoying. I additionally really feel like I’m lacking a particular relationship; I’ve supportive household and would love a romantic friendship. I mentioned Hello to my finest pal at work I’ve a crush on her. It felt good to see her earlier than I left work as she was coming in to work. I really feel comfy speaking to her with ease, she is type, good, and listener. I really feel our friendship is regularly rising.”
HPI: Edwin is a 34-year outdated Hispanic male who involves the clinic complaining of melancholy and anger. He’s experiencing a poor relationship with folks. He feels trapped and insecure.
(embrace psychiatric ROS rule out)
Previous Psychiatric Historical past:
• Basic Assertion: Recognized with melancholy final yr.
• Caregivers (if relevant): Lives with each dad and mom and two sisters
• Hospitalizations: No previous hospitalizations.
• Treatment trials: Multivitamin each day,
• Psychotherapy or Earlier Psychiatric Analysis: Psychotherapy twice every week. Analysis: Autism Spectrum Dysfunction and Temper D/O associated to ASD
Substance Present Use and Historical past: No historical past of substance use
Household Psychiatric/Substance Use Historical past: No household historical past for psychiatric or substance use.
Psychosocial Historical past: Edwin works at an area manufacturing plant. He has no historical past of alcohol or drug abuse. He lives along with his dad and mom.
Medical Historical past:

• Present Drugs: No medicine
• Allergic reactions: No recognized allergy symptoms
• Reproductive Hx: The affected person is just not sexually lively and has no youngsters. He’s planning to marry sooner or later.
ROS:
GENERAL: No unintentional physique weight improve or lower. No fever or chills.
HEENT: No nasal congestion, sore throat, or teary eyes.
SKIN: No pores and skin rashes, itching, sores, or bruises.
RESPIRATORY: No shortness of breath, coughing, or sputum.
CARDIOVASCULAR: No chest stress, palpitation, chest ache, or tightness of the chest.
MUSCULOSKELETAL: Damaging for again ache, myalgias, arthralgias, and gait downside.
NEUROLOGICAL: No dizziness or headache.
PSYCHIATRIC: Optimistic for melancholy and anger.
ENDOCRINOLOGIC: Damaging for irregular sweating.
REPRODUCTIVE: Not sexually lively and single.
ALLERGIES: No recognized allergy symptoms for climate modifications, mud, or pollen.
Goal:
Diagnostic outcomes: adverse outcomes for anemia or thyroid.
Assessment:
Psychological Standing Examination: Damaging for dementia with a rating of 28/30.
Differential Diagnoses:
Autism Spectrum
Autism spectrum dysfunction is a fancy developmental situation that entails persistent challenges in social interactions. The signs of the dysfunction embrace problem in understanding others, anxiousness, impolite conversations with different folks, discovering it laborious to specific opinions (Grove et al., 2019). The DSM-5 standards aligns with the present signs together with failure to make high quality relationships, irregular social method, lack of curiosity in friends. In line with the affected person’s chief criticism, he’s discovering it laborious to make mates and is afraid of injuring them, and problem in understanding others. Anger is build up inside him and he feels trapped.
There isn’t a medicine for folks with ASD, therapy strategies are supposed to enhance the standard of life by suppressing the signs. Among the finest therapy strategies embrace occupational remedy, bodily remedy, and pharmacology (Grove et al., 2019). In some circumstances, youngsters who current with ASD might expertise a discount of the severity of the signs as they develop up.
Social Nervousness
Soial anxiousness is a dysfunction that causes social phobia or worry in social settings. Individuals who undergo from social anxiousness have issues attending social occasions, assembly folks or speaking to new folks (Leichsenring & Leweke, 2017). The premise of the worry is to judged by others. The signs embrace irrational worry, embarrassment, extreme worry, and the worry of offending others. Calls for or stress might trivver social anxiousness dysfunction (Leichsenring & Leweke, 2017). Speak remedy is a vital therapt that may Help the sufferers to enhance confidence and interplay with others.
Main depressive dysfunction
Main depressive dysfunction is a psychological well being dysfunction that triggers a persistent depressive temper and lack of curiosity in each day actions. Despair causes a change within the mind’s chemical composition and functioning (Layton et al., 2019). The dysfunction triggers behavioral and bodily signs. Among the signs embrace lack of curiosity in each day actions, change in sleep patterns, low urge for food, and low vanity (Hasin et al., 2018). The psychological dysfunction can alter the lifetime of an individual drastically by affecting their relationships with different folks.
Borderline persona dysfunction
A borderline persona dysfunction is a psychological situation that impacts how people really feel about themselves and others. The modifications in perceptions and emotions have an effect on relationships and the power to take part in each day actions (Hasin et al., 2018). Among the indicators of the issues embrace self-image points and unstable relationships with folks. Different signs of BPD embrace self-destructive habits, emotional swings, a persistent feeling of vacancy, and explosive anger (Hasin et al., 2018). Sufferers with BPD require elaborate therapy because the dysfunction can undermine the standard of their life.
Adjustment dysfunction with depressed temper
Adjustment dysfunction is an emotional and behavioral response to tense life occasions. The situation triggers an unhealthy and unstable response to life occasions. For instance, some folks expertise adjustment dysfunction inside three months after a serious life occasion happens (Chanen et al., 2020). Among the modifications might embrace relocating, separation or divorce, marital difficulties, retirement, dropping a job, or shifting to a brand new faculty (Chanen et al., 2020). Therapy of adjustment dysfunction requires psychotherapy, help teams, and household remedy.
Reflections:
The case examine of the affected person exhibits the modifications in private life are affecting the temper and psychological situation of the affected person. The affected person appreciates that the pandemic is a serious set off of the present psychological dysfunction. Signs are affecting the connection with different folks and making the affected person indignant. Instant therapy is important to keep away from the disruptions which will create poor relationships with different folks (Maerckers & Lorenz, 2018). The therapy choices require each psychotherapy and pharmacological methods. You will need to emphasize the significance of adherence to the psychotherapeutic approaches and pharmacological remedies.
Sufferers with autistic situations require help from relations and mates. Household remedy is important to make sure they perceive the affected person’s situation. Help will relieve the severity of the signs and enhance the standard of life. One other form of help is from teams of individuals dwelling with autism. You will need to advocate the help to make sure the affected person enjoys each day actions. Supporting them makes them really feel loves and worthy.
Case Formulation and Therapy Plan:
The case formulation of the autism spectrum consists of particular genes that improve the danger of the dysfunction (Grove et al., 2019). The prevalence is excessive with the complicated interplay of genetic, nongenetic, and environmental elements.
The perfect therapy strategies embrace occupational remedy, bodily remedy, and pharmacology. Sufferers ought to begin the remedy early to make sure profitable therapy. Utilized habits remedy is among the widespread strategies of offering care to sufferers in faculties or clinics (Grove et al., 2019). The aim of utilized habits remedy is to encourage constructive behaviors that enhance high quality of life and discourage adverse behaviors (Grove et al., 2019). Mother and father or academics ought to encourage the kids by being emphatic, making the kids really feel protected and beloved.
The main focus of autism therapy is to cut back the severity of the signs. The household can contemplate animal Helped remedy. Animal-Helped remedy is to enhance bodily, emotional, and social wellbeing of individuals dwelling with autism. The long-term resolution is essential to enhance the lifetime of the affected person. One other needed therapy method is anger administration that entails minimizing harmful emotional outbursts. Anger administration improves the social lifetime of a affected person at school and workplaces. Embracing numerous therapy strategies minimizes the the signs and helps sufferers to dwell a traditional life.
Conclusion
The signs of autism spectrum dysfunction embrace problem in understanding others, anxiousness, impolite conversations with different folks, discovering it laborious to specific opinions. The affected person within the case examine has related signs that align with the DSM-5 standards. The signs embrace failure to make high quality relationships, irregular social method, lack of curiosity in friends. Therapy entails occupational remedy, bodily remedy, and pharmacology. Whereas autism has no recognized treatment, therapy reduces the severity of the signs and improves potential to take part in each day actions.

References
Chanen, A. M., Nicol, Okay., Betts, J. Okay., & Thompson, Okay. N. (2020). Analysis and therapy of borderline persona dysfunction in younger folks. Present Psychiatry Reviews, 22(5), 1-Eight.
Grove, J., Ripke, S., Als, T. D., Mattheisen, M., Walters, R. Okay., Received, H., … & Børglum, A. D. (2019). Identification of widespread genetic danger variants for autism spectrum dysfunction. Nature Genetics, 51(three), 431-444.
Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of grownup DSM-5 main depressive dysfunction and its specifiers in america. JAMA Psychiatry, 75(four), 336-346.
Layton, T. J., Barnett, M. L., Hicks, T. R., & Jena, A. B. (2018). Consideration deficit–hyperactivity dysfunction and month of college enrollment. New England Journal of Drugs, 379(22), 2122-2130.
Leichsenring, F., & Leweke, F. (2017). Social anxiousness dysfunction. New England Journal of Drugs, 376(23), 2255-2264.
Maercker, A., & Lorenz, L. (2018). Adjustment dysfunction prognosis: Enhancing medical utility. The World Journal of Organic Psychiatry, 19(sup1), S3-S13.

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