Comprehensive Psychiatric Evaluation of a Schizophrenia Patient-Nursing Paper Examples

Patient Initials: F.M. (Psychiatric Evaluation)

Gender: Male

SUBJECTIVE:

CC: “My parents called for the appointment because they believe I am experiencing difficulties in school.”

HPI: The patient is a 21-year-old Caucasian male presenting at the clinic after his parents called for the appointment. The parents say the patient is experiencing difficulties in school. The patient has minimal insight into the circumstances surrounding his parents calling in for the appointment. Consequently, the patient seems to hallucinate and has inconsistent speech. The patient perceives life and college as mysterious (Psychiatric Evaluation).

The patient has a roommate whom he prefers not to talk about. He reports that the roommate put a microwave in their room but cannot say a word about it. The patient believes there are microwaves in the interview room and the surroundings, but they will spare him and the interviewer because someone is with him. He believes the room is spying on him and requests silence when the interviewer tries to ask a question (Psychiatric Evaluation).

Substance Current Use and History: F.M denies substance and alcohol abuse

Family Psychiatric/Substance Use History: Unknown

Past Psychiatric History: (Psychiatric Evaluation)

Hospitalization: No previous hospitalizations

Medication trials: No previous medical trials

Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnosis

Medical History: Patient denies any past medical history

• Current Medications: No current medications  
• Allergies: None reported
• Reproductive Hx: Sexually active.

ROS:  

General: Reports minimal weight loss and denies fever, chills, weakness, or fatigue.

HEENT: Eyes: Patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. The patient reports a loss of appetite.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color

Neurological Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. The patient reports difficulties concentrating and paying attention.  

Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Denies sweating. No reports of cold or heat intolerance. No polyuria or polydipsia.

OBJECTIVE:

Vital signs: Stable

Temp: 97.9F

            B.P.: 140/85

            H.R.: 70

             R.R.: 17

             O2: Room air

             Pain: 1/10

             Ht: 70 inches

             Wt: 122 lbs

             BMI: 17.5

             BMI Range: Underweight

LABS:

Neutrophils 55%,

Lymphocytes 22%,

Monocytes 5%,

GGT 29,

Total cholesterol 108,

Phosphate 3.1,

Remainder WNL

Physical Exam:

General appearance: The patient appears in good health but not well nourished, with the BMI indicating he is underweight. The patient initially converses appropriately and regularly but diverts and demonstrates inconsistent speech and conversation mid-interview. As a result, it is difficult to understand what the patient is saying. The patient maintained cooperation initially but diverted conversation mid-course (Psychiatric Evaluation).

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. Consequently, no palpitation. No peripheral edema to palpation bilaterally.

Cardiovascular: The patient’s heartbeat and rhythm are regular. The patient’s heart rate is constant, and capillaries refill in two and a half seconds.  

Musculoskeletal: Normal range of motion. Low muscle mass for age. No signs of swelling or joint deformities.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear initially but unclear mid-interview. In addition, the patient indicates signs of A/V hallucinations and delusional thoughts.  

Psychiatric: The patient is attentive and cooperative initially but diverts conversation mid-course and becomes difficult to understand.

Neuropsychological testing: The patient has challenges executing school work and house functions. Social-emotional functioning is limited.

Behavior/motor activity: Patient behavior was appropriate and constant throughout the assessment (Psychiatric Evaluation).

Gait/station: Stable.

Mood: The patient exhibited an “okay” mood.

Affect: The patient is significantly detached mid-interview.  

Thought process/associations: comparatively not linear and lack direction. Thoughts are markedly tangential

Thought content: Thought content is fairly scattered and does not stay on one topic. Noted significant signs of A/V hallucinations, delusional thoughts, and paranoia.

Attitude: The patient was variably cooperative during the interview, requiring redirection to respond to some questions. Moreover, the patient is well-groomed, and the hair is combed. The patient’s appearance is cachectic. 

Orientation: Oriented to self and general timeframe only and not to place and situation (Psychiatric Evaluation).

Attention/concentration: fair

Insight: fair

Judgment: Good initially, but becomes absent mid-course.

Remote memory: considered good

Short-term memory: considered fair

Intellectual /cognitive function: considered fair

Language: clear speech initially, becomes inconsistent mid-course. The tone is assessed to be normal

Fund of knowledge: Fair.

Suicidal ideation: The patient denies any suicidal ideation and is negative for active plans or intent.

Homicide ideation: Negative.

ASSESSMENT:

Mental Status Examination:

The patient is a 21-year-old White male presenting at the clinic with difficulties in school. Furthermore, patient behavior was appropriate and constant throughout the assessment. The patient had a stable gait and exhibited an “okay” mood. Consequently, The patient is significantly detached mid-interview. His thought process/associations are comparatively not linear and lack direction. Thoughts are markedly tangential. Moreover, His thought content is fairly scattered and does not stay on one topic (Psychiatric Evaluation).

The patient demonstrated signs of A/V hallucinations, delusions, and paranoia. Consequently, the patient was variably cooperative during the interview, requiring redirection to respond to the questions. On the other hand, the patient is well-groomed, and the hair is combed. Moreover, the patient’s appearance is cachectic. Subsequently, the patient was oriented to self and general timeframe only and not to place and situation (Psychiatric Evaluation).

His attention/concentration is fair, his insight is fair, and his judgment is good initially. However, he becomes absent mid-course, remote memory is considered good, short-term memory is considered fair, and intellectual /cognitive function is considered fair. The patient has a clear speech initially but becomes inconsistent mid-course. Consequently, the tone is assessed to be normal, fund of knowledge is fair. Furthermore, the patient denies any suicidal ideation and is negative for active plans or intent and homicide ideation (Psychiatric Evaluation).

Differential Diagnosis:

Schizophrenia:

Schizophrenia remains a functional disorder marked by delusional beliefs, hallucinations, thoughts, perceptions, and behavior disturbances. Consequently, Schizophrenia symptoms remains divided into positive and negative symptoms.Moreover, with positive symptoms being hallucinations and formal thought disorders. In addition, hallucinations and negative symptoms being poverty of speech, anhedonia, and lack of motivation (Jain & Mitra, 2021). Consequently, Schizophrenia remains diagnosed exclusively after getting a comprehensive psychiatric history and accepting other causes of psychosis(Psychiatric Evaluation).

The DMS-5 criteria for schizophrenia require two or more symptoms, including delusions, hallucinations, disorganized speech, grossly disorganized, catatonic behavior, and negative symptoms, to be present for a significant period to confirm the diagnosis (Jain & Mitra, 2021). In addition, the patient must present with social or occupational dysfunction and signs of disturbance. Besides, based on the DMS-5 criteria and symptomology the patient presents, schizophrenia remained confirmed (Psychiatric Evaluation).

Bipolar Affective Disorder

Bipolar affective disorder is chronic and complex, marked by bipolar mania, hypomanic, and depressive episodes. Patients also indicate subsyndromal symptoms appearing in between mood episodes. Generally, patients appear hyperkinetic, unpredictable, and erratic. Consequently, their mood is elevated, affect is intense or heightened, speech is pressured, and patients present with mood-congruent delusions (Jain & Mitra, 2021) (Psychiatric Evaluation).

Consequently, patients remain easily distracted, have limited concentration, and indicate grandiosity in delusions. Furthermore, patients have limited insights and are unreliable in the information they share. Schizophrenia can present with mood features similar to bipolar affective disorder; however, these symptoms manifest exclusively in thought disorder settings (Jain & Mitra, 2021). This diagnosis remained refuted because the patient did not indicate depressive episodes, mania, or hypomanic episodes (Psychiatric Evaluation). 

Paranoid Personality Disorder

Initially, paranoid personality disorder remained theorized as linked to schizophrenia because the two disorders are phenomenologically related. consequently, Suspiciousness has some similarities to paranoid delusion. Moreover, PPD patients are suspicious, unforgiving, ruminative, and possess jealous traits. Patients also indicate excessive self-importance, are hostile to others and have expansive, fanatic, querulant, and sensitive paranoid personality subtypes (Lee, 2018). To confirm PDD diagnosis, psychotic symptoms, such as hallucinations and paranoid delusions, typically associated with schizophrenia, remains exempted, and the diagnosis refuted (Psychiatric Evaluation).  

PLAN:

A combination of psychotherapy and medication will help achieve better patient outcomes.

Safety Risk/Plan:

The minimal likelihood of causing harm to others and self was assessed. No admissions are required.

Pharmacologic interventions:

Second-generation antipsychotics (SGA), including aripiprazole, olanzapine, asenapine, and quetiapine, are recommended for the initial treatment of psychosis. Consequently, Benzodiazepines like diazepam, lorazepam, and clonazepam are recommended to control behavioral disturbances and mild anxiety. Trifluoperazine and fluphenazine will be used as first-line treatment to control the acute phase before switching to aripiprazole and paliperidone to enhance medication adherence and compliance, enhancing patient outcomes and minimize relapses (Jain & Mitra, 2021). Clozapine will help with treatment resistance in case of poor response to other drugs (Psychiatric Evaluation).    

Psychotherapy:

Cognitive Behavioral Therapy: CBT techniques like art and drama therapies effectively counterbalance the negative symptoms associated with schizophrenia (Jain & Mitra, 2021). These techniques will help improve insight and reduce or prevent relapses (Psychiatric Evaluation). 

Education:

1. Educate the patient about toxicity, side effects, possible complications, and the importance of medication adherence.
2. Educate the patient about the need to make and maintain healthy lifestyle choices.
3. Insist on the healthcare team as allies the patient can always rely on to promote disease management.  
4. Advise the patient to join a support group or group therapy to help develop social-emotional skills.

Enhancing Patient Outcomes

1. The patient’s WBC should be measured regularly to reduce the risk of agranulocytosis associated with clozapine.
2. Signs of relapse should be monitored frequently. 

Consultation/follow-up: Follow-up is in one week.  

Reflection

Schizophrenia significantly impacts people and society, contributing to most morbidities and disabilities associated with psychotic disorders. Moreover, It impacts social and occupational functioning and makes schoolwork challenging to accomplish. Consequently, Unemployment among schizophrenia patients is considerably high, and it reduces life expectancy and increases healthcare costs. Addressing schizophrenia is challenging for any healthcare practitioner because effective and acceptable treatment regimens are still a research challenge affecting modern medicine (Psychiatric Evaluation).

Assessing and diagnosing this patient and researching evidence-based approaches to treatment indicates hope for schizophrenia patients because opportunities for progress are much better with substantive advances in genomics, epidemiology, and neuroscience application to schizophrenia. Furthermore, from an ethical perspective, dealing with schizophrenia patients is a challenge regarding autonomy and truth-telling aspects conflicting with principles of beneficence and nonmaleficence.

The patients mainly provide unreliable information, and practitioners must involve parents or caregivers despite the patient being an adult. Respect for person and their worth and dignity creates ethical dilemmas in schizophrenia cases. Given another chance with the patient, I would dig deeper into the patient’s childhood to determine any early signs and involve parents in the interview to obtain a comprehensive and full psychiatric history (Psychiatric Evaluation).        

References

Hany, M., Rehman, B., & Azhar, Y. (2022). Schizophrenia. In StatPearls [Internet]. StatPearls Publishing.

Jain, A., & Mitra, P. (2021). Bipolar affective disorder. In StatPearls [Internet]. StatPearls Publishing.

Lee R. (2018). Mistrustful and Misunderstood: A Review of Paranoid Personality Disorder. Current behavioral neuroscience reports, 4(2), 151–165. https://doi.org/10.1007/s40473-018-0116-7