NRNP 6635 Week 5: Comprehensive Psychiatric Evaluation and Patient Case Presentation Example

 

Chief Complaint (CC):

 	
A 36-year-old male presenting with restlessness, agitation, disorganized speech, impaired cognition, and periodic delusions.

History of Present Illness (HPI):

 	
Symptoms have fluctuated over three weeks with episodes of restlessness alternating with lack of motivation and withdrawal. Delusions and hallucinations have persisted for four weeks.

Past Psychiatric History:

 	
Diagnosed with bipolar disorder 10 years ago and schizophrenia at age 30. Non-adherence to medication is a noted issue.
 	
History of one hospitalization following a suicide attempt.
 	
Previous and current medications are detailed, including issues experienced with fluphenazine.

Substance Use History:

 	
History of binge drinking, cigarette, and cannabis use since his undergraduate years. Still smokes cigarettes and drinks alcohol occasionally.

Family Psychiatric/Substance Use History:

 	
Schizophrenia in the paternal grandfather and a family history of substance use (cigarette smoking, alcohol).

Psychosocial History:

 	
Married with one child, working as a software engineer. History of violent behavior leading to arrest and imprisonment.

Medical History:

 	
History of head injuries from violent behavior and a minor car accident, as well as past hospitalization for malaria.

Current Medications:

 	
Sodium valproate, sertraline, alprazolam, and aripiprazole.

Allergies:

 	
None.

Reproductive History:

 	
Heterosexual, married with one child, sexually active with occasional withdrawal during symptom flares.

Review of Systems (ROS):

 	
General: Weight gain.
 	
HEENT: Normal.
 	
Skin: Warm, normal turgor.
 	
Cardiovascular: Normal BP and heart rate.
 	
Respiratory: Normal.
 	
Gastrointestinal: Normal.
 	
Neurological: Tingling in limbs and difficulty moving feet.
 	
Musculoskeletal: Stiffness in lower extremities.
 	
Other systems are unremarkable.

Diagnostic Results:

 	
Head CT scan showed no physical injury.
 	
Blood tests revealed positive for alcohol, cigarette, and cannabis use.

Mental Status Examination:

 	
Appropriately dressed, aware of time and occasion.
 	
Admitted to suicidal ideation.

Differential Diagnoses:

 	
Schizophrenia, Bipolar Disorder, Major Depressive Disorder.
 	
Schizophrenia is diagnosed based on DSM-5 criteria.

Reflections:

 	
The diagnosis of schizophrenia requires careful assessment, supported by symptom clusters and appropriate diagnostics. The case reinforced the need for a compassionate approach to psychiatric care, emphasizing public education on modifiable risk factors like substance abuse.