Posted: October 6th, 2022

Comprehensive Psychiatric Assessment Note and Patient Case Presentation

Week 7: Comprehensive Psychiatric Assessment Note and Patient Case Presentation

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

Patient Info:
M.R. 28 yr outdated Hispanic feminine
Initials: M.R., Age: 28 y.o, Intercourse: Feminine, Ethnic: Hispanic
Subjective:
CC (chief criticism): Binge consuming and impulse management.
HPI: M.R. is a 28-year-old Hispanic feminine who presents to the clinic with a consuming drawback for additional analysis. He complains of a consuming drawback conduct. His PCP referred her to the clinic for analysis and remedy. She has been in psychotherapy for 3 months. Her boyfriend has a consuming drawback as properly. She has no treatment to alleviate the outcomes of the consuming drawback.
Previous Psychiatric Historical past:
• Common Assertion: The affected person has no historical past of psychiatric circumstances.
• Caregivers (if relevant): A nurse attended to her after a knee damage and prescribed ibuprofen to alleviate the ache.
• Hospitalizations: The affected person has no historical past of hospitalization.
• Remedy trials: The affected person has no historical past of medical trials.
• Psychotherapy or Earlier Psychiatric Prognosis: The affected person had psychotherapy in highschool after abusing medication. She has been underneath psychotherapeutic remedy for 3 months.
Substance Present Use and Historical past: The affected person has a historical past of abusing alcohol.
Household Psychiatric/Substance Use Historical past: The daddy operates a on line casino and is aggressive about playing video games and frequent alcohol use. She steadily visits the on line casino together with his boyfriend. Her father is an addict to alcohol and cigarettes. Her solely elder sister is hooked on alcohol. Her sister is hooked on marijuana and tobacco.
Psychosocial Historical past: The affected person was born and raised in California State. She has one brother and lives with the boyfriend. He’s single and working on the native college as a librarian. She is pursuing a Grasp’s of schooling in literature. He has been courting the boyfriend for months. Dad and mom from each side are Mexican Individuals. She visits the households twice yearly. She complains the household is usually intrusive.
Medical Historical past:
• Present Medicines: Ibuprofen and multivitamin pill.
• Allergy symptoms: No recognized drug allergic reactions.
• Reproductive Hx: She is sexually lively and has no kids. No historical past of being pregnant.
Goal:
Diagnostic outcomes: Alcohol use dysfunction
Assessment:
Psychological Standing Examination: M.R. is a 28-year-old Hispanic feminine who appears to be like the said age. She is cooperative throughout the interview. The affected person is neat and groomed for the event. She is wanting regular with out indicators of motor exercise dysfunction. The speech is obvious, and the tone is acceptable. The thought course of is logical. Delicate hallucinations, lack of concepts, and irregular temper. No delusional considering or suicidal ideation. The affected person is alert and oriented. The short-term and long-term reminiscence is undamaged.
Differential Diagnoses:
Alcohol use dysfunction
Alcohol use dysfunction is a sample of unhealthy consumption of alcohol that may vary from delicate to extreme. The signs embody the shortcoming to cut back consumption regardless of compelling wishes, spending a lot time and sources consuming, and neglecting work and household obligations (Kranzler & Soyka, 2018). The dysfunction is obvious when a person consumes numerous alcohol or when it’s withdrawn. Danger components embody regular consuming over time, consuming at an early age, social and cultural components, historical past of bariatric surgical procedure, and household historical past (Witkiewitz et al., 2019). The dysfunction can have an effect on the mind, muscle coordination, and high quality of speech. Heavy consuming or extreme dysfunction could result in coma or loss of life (Witkiewitz et al., 2019). It could result in different well being points resembling liver illness, coronary heart issues, digestive issues, congenital disabilities, eye issues, and sexual dysfunction.
Intermittent Explosive Dysfunction
The situation entails unwarranted anger and behavioral outbursts that don’t match the scenario. The signs of intermittent explosive dysfunction embody rage, irritability, racing ideas, tingling, palpitations, elevated vitality, and tremors. The reason for the dysfunction is unknown however genetic components, provocation, and mind chemistry. Therapy and prevention entails altering the atmosphere, resolving variations, and sticking to treatment.
Melancholy
Folks with substance or alcohol use dysfunction can develop melancholy since they expertise frustrations once they notice they can not management their conduct. Melancholy is obvious amongst folks utilizing medication or alcohol (Hasin et al., 2018). Melancholy happens when folks neglect their households, lose their jobs, and use all their funds on a drug. The signs of melancholy embody hopelessness, guilt, worthlessness, and self-hate (Hasin et al., 2018). People can expertise melancholy after a major life occasion resembling divorce, job loss, or traumatic life occasion.
Reflections:
Case Formulation and Therapy Plan:
Initiation of particular person psychotherapy with a counselor. The affected person might be referred to a counselor for extra intervention to deal with the alcohol use dysfunction. Documentation of the affected person sources, together with the affected person telephone numbers, deal with, subsequent of kin, and subsequent appointment date, is important. Patient schooling will encourage the affected person to stick to the remedy plan (Witkiewitz et al., 2019).
The consumer can name 911 in case of an emergency or go to the emergency room in case of suicidal ideation. The healthcare facility can comply with up on the affected person by way of his telephone quantity (555) 555-1234.
The consumer can have a chance to ask questions concerning the remedy. Energetic listening is important within the provision of look after sufferers with psychological problems. Energetic listening builds belief and rapport with a affected person. Knowledgeable consent might be essential earlier than the execution of the remedy (Witkiewitz et al., 2019).
Psychological standing examination crucial is Hamilton Anxiousness Ranking Scale (HAM-A) to evaluate the affected person’s response to the remedy and rule out different psychological circumstances resembling melancholy.
The affected person ought to take Naltrexone to cut back the will to drink (Kranzler & Soyka, 2018). One other type of remedy is self-help teams that contain speaking with different individuals who have overcome the alcohol use dysfunction. CBT is critical to the person adjustments their perfection about life and considering patterns. The affected person ought to take antidepressants resembling Zoloft 50mg PO each day.
The affected person ought to return to the clinic after 4 weeks for additional Assessment. It’s anticipated that the affected person will overcome the consuming dysfunction or scale back the severity considerably. The indications of restoration will embody consuming extra miniature bottles and spending much less time and cash on alcohol.
I’ve realized that alcohol use dysfunction requires collaboration with completely different stakeholders resembling counselors, relations, and the affected person’s lively involvement. Combining psychotherapy with pharmacology remedy is important to extend the possibilities of restoration. Hamilton Anxiousness Ranking Scale (HAM-A) is important to evaluate the extent of restoration and rule out some circumstances resembling melancholy.
Conclusion
Psychiatric analysis and remedy of sufferers with alcohol use dysfunction is a posh endeavor. The case research of a affected person with alcohol use dysfunction requires a mix of psychotherapy and pharmacology remedy to reinforce restoration possibilities. Naltrexone 50mg each day is critical to cut back alcohol use dysfunction. The affected person ought to attend all of the psychotherapy classes and adhere to all of the treatment. The affected person ought to return to the clinic after 4 weeks for additional Assessment.

References
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.
Jones, C. M., & McCance-Katz, E. F. (2019). Co-occurring substance use and psychological problems amongst adults with opioid use dysfunction. Drug and Alcohol Dependence, 197, 78-82.
Kranzler, H. R., & Soyka, M. (2018). Prognosis and pharmacotherapy of alcohol use dysfunction: a assessment. Jama, 320(eight), 815-824.
Witkiewitz, Ok., Litten, R. Z., & Leggio, L. (2019). Advances within the science and remedy of alcohol use dysfunction. Science Advances, 5(9), 4043.

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