NRNP 6635: Psychopathology and Diagnostic Reasoning Paper

NRNP 6635: Psychopathology and Diagnostic Reasoning Paper

NRNP 6635: Psychopathology and Diagnostic Reasoning Paper

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Subjective:
CC (chief complaint): “I have come for a psychiatric assessment.”
HPI: Sergeant Patrick Flanrey is a 27-year-old male who comes to the psychiatric clinic. He states that his fiancé insisted he should be seen by a psychiatrist. She told him to seek psychiatric assessment after he was frightened by fireworks during a count fair and he tried to escape. Patrick states that the sound of the fireworks reminded him of the days he was in combat and he felt like he had returned to the center of enemy fire. He also reports that he is startled by loud noises, which remind him of combat days. Burn smells offset him as they remind him of his colleague who was razed when their Humvee was blown. He reports getting daily nightmares related to combat events. Furthermore, Patrick reports getting anxious when in traffic because he pictures someone rolling an IED under the car and blowing him like what happened to his colleagues and two vehicles he had witnessed. The patient tries to run away from any negative situation and avoids public places and would rather stay in his room all day and avoid sleeping due to nightmares.

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Past Psychiatric History:
• General Statement: No significant psychiatric history
• Caregivers (if applicable): None
• Hospitalizations: None
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: None
Substance Current Use and History: He denies smoking, using alcohol, or illicit drugs.
Family Psychiatric/Substance Use History: Patrick’s father has a history of excessive alcohol use. He currently has DM, liver disease, and HTN and continues to take alcohol. His paternal grandfather was also a veteran and was diagnosed with depression occasionally. His mother is alive and well and is the primary caregiver to his sick father.
Psychosocial History: Sergeant Patrick is a veteran currently working as a furniture salesman. He joined the military after completing high school and had been sent for three long tours of duty in warzones. He resigned from active duty in the Marines a couple of months ago after eight years in the military. He is engaged and is set to marry his fiancé in a year or two. He plans to have kids later. He has one older and younger sister. He lives in a different state, roughly five hours from his parents and siblings.
Medical History: History of Service-related asthma.

• Current Medications: None
• Allergies: Seasonal allergies.
• Reproductive Hx: No STDs.
ROS:
• GENERAL: Negative for fatigue, fever, chills, or weight changes.
• HEENT: Negative for vision changes, eye pain, ear pain/discharge, hearing loss, rhinorrhea, sneezing, or sore throat.
• SKIN: Denies rashes, color changes, or bruises.
• CARDIOVASCULAR: SOB when anxious. Negative for chest pain, SOB on exertion, or palpitations.
• RESPIRATORY: Negative for chest pain, cough, or sputum production.
• GASTROINTESTINAL: Negative for nausea, vomiting, abdominal pain, or diarrhea/constipation.
• GENITOURINARY: Negative for dysuria, penile discharge, or urinary symptoms.
• NEUROLOGICAL: Negative for headache, dizziness, fatigue, muscle weakness, or tingling sensations.
• MUSCULOSKELETAL: Negative for back/muscle pain, joint stiffness, or joint pain.
• HEMATOLOGIC: Negative for anemia or easy bruising.
• LYMPHATICS: Negative for enlarged lymph nodes.
• ENDOCRINOLOGIC: Positive for excessive sweating when in traffic because of anxiety.
Objective:
Physical exam: Vital Signs: BP-134/88; Temp- 97.4; P- 84; R-18; Ht-5’8; Wt-167lbs
Diagnostic results: No lab tests were ordered.
Assessment:
Mental Status Examination:
The patient is a 27-year-old male. He is well-groomed and dressed appropriately for the event and weather. He is alert and in no apparent distress. He maintains adequate eye contact. His self-reported mood is nervous, and his affect is appropriate. His speech is clear, but volume varies when narrating about his combat experiences. He has a coherent and logical thought process. He exhibits no delusions, hallucinations, obsessions, or suicidal/homicidal thoughts. He has an intact short- and long-term memory and has a clear judgment.
Differential Diagnoses:
Post-Traumatic Stress Disorder (PTSD): PTSD occurs when an individual is exposed to actual or threatened: serious injury, death, or sexual violence. This can be through direct exposure, witnessing, or learning that a loved one experienced a traumatic event (Bryant, 2019). PTSD is characterized by avoidance, intrusion symptoms, negative impact on cognition and mood, and changes in arousal and reactivity (Miao et al., 2018).
Sergeant Patrick exhibits altered arousal and reactivity from traumatic triggers like loud noises, fireworks, and burning smells. He has intrusive thoughts of the combat events and reports having nightmares. He has avoidance symptoms evidenced by avoidance of public places due to fear of being exposed to traumatic triggers and avoiding discussing the combat experience. In addition, he has alterations in mood as he usually gets anxious when in a situation that reminds him of combat events.
Panic Disorder
Sergeant Patrick has clinical features consistent with Panic disorder like a feeling of shortness of breath, sweating, and shaking, when he is in traffic. Nevertheless, this fails to meet the DS-V diagnostic criteria for panic disorder since the symptoms are triggered by specific circumstances (Manjunatha & Ram, 2022).
Social Phobia
The patient avoids public places and would rather spend an entire day in his room, which leads to the differential diagnosis of Social phobia. Nevertheless, the patient’s avoidance of public places is not due to a phobia but is a way to avoid negative situations that will trigger combat memories (Jefferies & Ungar, 2020). This makes social phobia a less likely primary diagnosis.
Reflections:
If I were to conduct the assessment again, I would assess the severity of the patient’s PTSD and anxiety symptoms using screening tools Clinician-Administered PTSD Scale (CAPS) and PTSD Checklist (PCL). I have learned from the assessment that diagnosing PTSD requires a more in-depth assessment. Ethical considerations include respect for patient autonomy, which entails involving the patient in clinical decision-making and respecting their decisions when creating the care plan (Bipeta, 2019). SDOH that may affect the patient includes access to healthcare, which will determine if he will access the recommended treatments for PTSD. Health promotion and disease prevention will focus on educating the patient on coping mechanisms to help him cope with the traumatic experiences effectively.

References
Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian Journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19
Bryant, R. A. (2019). Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges. World Psychiatry, 18(3), 259-269. https://doi.org/10.1002/wps.20656
Jefferies, P., & Ungar, M. (2020). Social anxiety in young people: A prevalence study in seven countries. PLoS One, 15(9), e0239133. https://doi.org/10.1371/journal.pone.0239133
Manjunatha, N., & Ram, D. (2022). Panic disorder in general medical practice- A narrative review. Journal of family medicine and primary care, 11(3), 861–869. https://doi.org/10.4103/jfmpc.jfmpc_888_21
Miao, X. R., Chen, Q. B., Wei, K., Tao, K. M., & Lu, Z. J. (2018). Posttraumatic stress disorder: from diagnosis to prevention. Military Medical Research, 5(1), 1-7. https://doi.org/10.1186/s40779-018-0179-0

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ASSESSING AND DIAGNOSING PATIENTS WITH ANXIETY DISORDERS, PTSD, AND OCD

Fear,” according to the DSM-5-TR, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2022). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease.

For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5-TR criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5-TR criteria.

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Required Readings

American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders

American Psychiatric Association. (2022). Obsessive compulsive and related disorders In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x06_Obsessive_Compulsive_and_Related_Disorders

American Psychiatric Association. (2022). Trauma- and stressor-related disorders.. In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders

Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

Chapter 8, “Anxiety Disorders”

Chapter 9, “Obsessive-Compulsive and Related Disorders”

Chapter 10, “Trauma- and Stressor-Related Disorders”

Chapter 2- only sections 2.13, “Anxiety Disorders of Infancy, Childhood, and Adolescence: Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder (Social Phobia)”; 2.14 “Selective Mutism” and 2.15 “Obsessive-Compulsive Disorder in Children and Adolescence”

Required Media

Classroom Productions. (Producer). (2015). Anxiety disordersLinks to an external site. [Video]. Walden University.

Classroom Productions. (Producer). (2012). The neurobiology of anxietyLinks to an external site. [Video]. Walden University.

Classroom Productions. (Producer). (2015). Obsessive-compulsive disordersLinks to an external site. [Video]. Walden University.

Classroom Productions. (Producer). (2015). Trauma, PTSD, and Trauma-Informed CareLinks to an external site. [Video]. Walden University.

MedEasy. (2017). Anxiety, OCD, PTSD and related psychiatric disorders | USMLE & COMLEXLinks to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=-BwzQF9DTlY

TO PREPARE:

Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing anxiety, obsessive-compulsive, and trauma- and stressor-related disorders.

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.

BELOW IS THE ASSIGNED VIDEO FOR THIS ASSIGNMENT. USE THE TRAINING- TITLE -21. PLEASE WATCH THE VIDEO BEFORE DEVELOPNINTHIS ASSIGNMENT.

Symptom Media. (Producer). (2016). Training title 21Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-21.

BELOW IS THE LINK

https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-21

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate 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 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.

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 taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

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).

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NRNP_6635_Week4_Assignment_Rubric

NRNP_6635_Week4_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate 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
20 to >17.0 pts

Excellent

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.

17 to >15.0 pts

Good

The response 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.

15 to >13.0 pts

Fair

The response 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, but is somewhat vague or contains minor innacuracies.

13 to >0 pts

Poor

The response provides an incomplete or inaccurate description of 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. Or, subjective documentation is missing.

20 pts
This criterion is linked to a Learning OutcomeIn 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.
20 to >17.0 pts

Excellent

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

17 to >15.0 pts

Good

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

15 to >13.0 pts

Fair

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

13 to >0 pts

Poor

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.

20 pts
This criterion is linked to a Learning OutcomeIn 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.
25 to >22.0 pts

Excellent

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.

22 to >19.0 pts

Good

The response 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 an accurate justification for each of the disorders selected.

19 to >17.0 pts

Fair

The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy.

17 to >0 pts

Poor

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.

25 pts
This criterion is linked to a Learning OutcomeReflect 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.).
10 to >8.0 pts

Excellent

Reflections are thorough, thoughtful, and demonstrate critical thinking.

8 to >7.0 pts

Good

Reflections demonstrate critical thinking.

7 to >6.0 pts

Fair

Reflections are somewhat general or do not demonstrate critical thinking.

6 to >0 pts

Poor

Reflections are incomplete, inaccurate, or missing.

10 pts
This criterion is linked to a Learning OutcomeProvide 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).
15 to >13.0 pts

Excellent

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.

13 to >11.0 pts

Good

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.

11 to >10.0 pts

Fair

Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.

10 to >0 pts

Poor

Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.

15 pts
This criterion is linked to a Learning OutcomeWritten 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.
5 to >4.0 pts

Excellent

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.

4 to >3.5 pts

Good

Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. …Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

3.5 to >3.0 pts

Fair

Purpose, introduction, and conclusion of the assignment is vague or off topic. … Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%-79% of the time.

3 to >0 pts

Poor

No purpose statement, introduction, or conclusion were provided. … Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation
5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors

4 to >3.0 pts

Good

Contains a few (one or two) grammar, spelling, and punctuation errors

3 to >2.0 pts

Fair

Contains several (three or four) grammar, spelling, and punctuation errors

2 to >0 pts

Poor

Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding

5 pts
Total Points: 100

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