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Psychopathology

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Comprehensive Psychiatric Evaluation

Tina Cherry

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Dr. Clark

April 30, 2022

Subjective:

CC (chief complain): Substance abuse disorder

HPI: The patient is a 26-year-old white female who has to the facility complaining of difficulties in sleeping. The patient is an alert and oriented person; that is, she is able to recognize her name, where she is, and a particular point in time. The patient has also lost a significant amount of weight within one week. The patient reports being diagnosed with Bipolar disorder previously, and she has been placed on medication which she complains has led her to have too much sleep at night. She has lost a significant amount of weight. The patient is generally a happy patient, as she rates her happiness at 8/10.

Past Psychiatric History:

· General Statement: “I needed help because I could not sleep.”

· Caregivers (if applicable): No information regarding caregivers is provided

· Hospitalizations: The patient has previously been hospitalized in a psychiatric facility because she was not able to sleep.

· Medication trials: During her admission to the psychiatric facility, the patient was placed on Gabapentin which was administered in dosages of 600mg in the morning and noontime and 1200 mg at night. She has been prescribed 5mg of Abilify at night. The patient also reports trying Lithium during her inpatient admission.

· Psychotherapy or Previous Psychiatric Diagnosis: The patient has been previously diagnosed with Bipolar 1 Disorder and mild depression.

Substance Current Use and History: No history of drug or alcohol abuse

Family Psychiatric/Substance Use History: No history of substance use or psychiatric condition of the patient’s family is provided

Psychosocial History: The patient has previously had episodes of mild depression and bipolar disorder. She was placed on medication to address her sleep problem. Medications administered in the past include Gabapentin 600mg one tab daily and 1.5 tab nightly. She was also placed on Aripiprazole 5 mg tab nightly. Her past medication examination reveals mild depression severity and mild anxiety, which is evident by a GAD-7 score of seven. According to Johnson et al.(2019), a GAD-7 score of 5-9 indicates that a patient has mild anxiety.

Medical History:

· Current Medications: The patient is currently being treated for Bipolar disorder with Gabapentin tabs administered in 600 mg tab daily, 600mg, 1.5mg tab nightly, and Aripiprazole 5 mg tab nightly

· Allergies: The patient is allergic to Lithium

Reproductive Hx: No has no history of reproductive health complications.

ROS:

· GENERAL: The patient has no addiction issues

· HEENT: No swelling on the patient’s head, and audio and visual acuity intact. The patient’s EOM is intact

· There is no sinus infection

· Mouth: There are no muscossal lesions

· Teeth; No significant resorption

· Pharynx: Mucosa non-inflamed

· Neck: thyroid non-enlarged

· SKIN: No rashes on the skin. The skin is adequately moist

· CARDIOVASCULAR: Pre-Hypertension, Normal heart rate, No chest pain.

· RESPIRATORY: No cough, clear to auscultation

· GASTROINTESTINAL: No abdominal pain or vomiting episodes

· GENITOURINARY: Negative dysuria

· NEUROLOGICAL: The patient is alert, and she answers questions accordingly.

· No facial asymmetry

· MUSCULOSKELETAL: The patient has adequate muscle tone.

· HEMATOLOGIC: The patient does not have anemia

· LYMPHATICS: No swollen lymph nodes present

· ENDOCRINOLOGIC: No endocrinal conditions noted

Objective:

Physical exam: : BP; 122/75. HR; 88 bpm. Ht/Lt; 5’11”. Wt; 153 lbs 9 oz. BMI; 21.42. Pain; 0/10

Diagnostic results: Blood and urine tests returned unremarkable results.

Assessment


Mental Status Examination
:

The patient is well-behaved. She is fairly groomed, and her hygiene is excellent. However, the patient feels restless throughout the interview process. Her speech is hyperverbal, stuttering initially; however, it improves as the conversation progresses. The patient has been previously hospitalized for bipolar disorder and shows no signs of highs and lows. The patient does not have suicidal or homicidal ideations; neither does she experience hallucinations but has difficulties finding sleeping patterns. PHQ-9 total score; 4. GAD-7 total score; 7

Differential Diagnoses:


Depression

Depression is a psychiatric illness that causes persistent feelings of sadness and loss of interest. Depression is classified into two categories; major depressive disorder and minor depression. Symptoms of minor depression include; anger, lack of interest or motivation, appetite changes, insomnia, weight changes, substance abuse, and pains with no particular cause (Tolentino & Schmidt, 2018). Symptoms reported by the patient include insomnia, weight loss, episodes of mania, and hypomania (Tolentino & Schmidt, 2018). Based on DSM 5 criteria for diagnosing minor depression, a patient must show at least the following symptoms; weight change, recurrent suicidal thoughts, insomnia, and hypersomnia every day, or at least one symptom must include anhedonia or dysphoria (Tolentino & Schmidt, 2018). Therefore, we can rule out the patient has mild depression.


Schizophrenia 

Schizophrenia is a mental illness in which patients interpret reality strangely. It might result in a combination of delusions, hallucinations, or extremely disorderly thinking or behavior s that may damage daily functioning (Carpenter, 2021). The most common symptoms of Schizophrenia based on DSM 5 criteria are; delusion, disorganized speech, hallucination, disorderly behaviors, and negative symptoms. In order to be diagnosed with Schizophrenia, at least two or more of the above symptoms must be present (Carpenter, 2021). The patient does not have delusions, disorganized speech, or hallucinations. The patient reports a lack of sleep and episodes of highs and lows. As such, she does not meet the DSM5 criteria for Schizophrenia.


Bipolar disorder

Bipolar disorder is a psychological illness that causes excessive mood swing, which includes episodes of high, lows, and depression. Studies show nearly half of people diagnosed with bipolar disorders will have a prevalence of mania and hypomania episodes—patients with Bipolar type 1 experience manic episodes and depressive disorders. On the hand, patients with bipolar type 2 will experience at least one episode of hypomania. Mania is the main DSM criterion for bipolar type 1, while hypomania is the differential diagnostic criteria of bipolar type 2. According to Kessing et al. (2021), manic patients engage in very risky activities such as substance abuse. They also experience sleep disturbances and restlessness. The patient experiences highs and lows and sleep disturbances and also exhibits some signs of minor depression. The symptoms of the patients meet the DSM criteria for diagnosis of bipolar type 1. Hence, we can rule that the patient has bipolar type 1 disorder.

Reflections

The patient is calm and very attentive. However, at some point, the patient becomes hypersensitive, and it becomes difficult to get the needed information from the patient. For instance, it was difficult to gather data related to patients’ family history of mental illness. Any attempt made to get information on family psychiatric and psychosocial history proved futile. I faced several communication barriers, possibly because I did not employ the right strategy. Presented with a similar situation in the future, I will employ therapeutic communication strategies such as the use of open-ended questions, allowing sufficient time to communicate with the patient, and assessing both verbal and nonverbal patient communication needs. According to Rønning and Bjørkly (2019), therapeutic communication enables the patient to feel safer and more comfortable. Creating an environment that promotes openness and trust creates a conducive environment that gives a patient the best experience possible, enabling them to respond to even sensitive questions. I will definitely employ this strategy to aid in gathering as much information as possible and enhancing patient outcomes.

References

Carpenter Jr, W. T. (2021). How the diagnosis of schizophrenia impeded the advance of knowledge (and what to do about it).

Johnson, S. U., Ulvenes, P. G., Øktedalen, T., & Hoffart, A. (2019). Psychometric properties of the general anxiety disorder 7-item (GAD-7) scale in a heterogeneous psychiatric sample. Frontiers in psychology10, 1713.

Kessing, L. V., González-Pinto, A., Fagiolini, A., Bechdolf, A., Reif, A., Yildiz, A., … & Vieta, E. (2021). DSM-5 and ICD-11 criteria for bipolar disorder: Implications for the prevalence of bipolar disorder and validity of the diagnosis–A narrative review from the ECNP bipolar disorders network. European Neuropsychopharmacology47, 54-61.

Rønning, S. B., & Bjørkly, S. (2019). The use of clinical role-play and reflection in learning therapeutic communication skills in mental health education: an integrative review. Advances in medical education and practice10, 415.

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: implications for clinical practice. Frontiers in psychiatry, 450.

© 2021 Walden University Page 8 of 8

Psychopathology

Comprehensive Psychiatric Evaluation

Tina Cherry

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Dr. Clark

April 21, 2022

Comprehensive Psychiatric Evaluation

Subjective

CC (Chief Complaint): Depression

HPI: 54-year-old white female. Individual reports depression has increased. “I been dealing with my boyfriend being in the nursing home. I have no desire to do anything. I just feel depressed and all I do is lay around crying.” Individual reports anxiety the same. She reports Seroquel helps with sleep and denies side effects from medications. Individual rates life 4/10 with 10 being the happiest. She denies SI/HI at this time.

Past Psychiatric History

General Information: The case is a 54-year-old female

Caregivers (If Applicable): The patient does not have a caregiver.

Hospitalizations: Inpatient psychiatric facility within the past 6 months

Medication Trials: No medical trials

Previous Psychiatric Diagnosis: Bipolar Disorder, Anxiety, and Depression

Substance Use and History: No history of substance abuse

Family History: Mother (deceased) cancer, mood disorder

Psychosocial History: Bipolar disorder, depression, and anxiety

Medical History: HTN/ COPD- Bronchitis/Emphysema/ Type II DM/ Hyperlipidemia

Current Medications:

Quetiapine 50 mg, Oxycarbazepine 300 mg, Fluticasone propionate 50 mcg, Loratadine 10 mg, Levothyroxine sodium 50 mcg, Montelukast sod 10 mg, Losartan potassium 50 mg, Novolog 100 units/ml vial; Diltiazem HCL ER coated BEA, VIT D2 1.25 mg (50,000 unit).

Allergies: The patient has no allergy, nor does she have any reaction to certain aspects such as seasonal changes, dust, or pollen.

Reproductive Hx: The patient began her menstrual periods at 15. The patient has no history of reproductive health complications.

Past Medical History: Bronchitis/Emphysema

ROS:

GENERAL: The patient is composed and well-presented. The patient’s speech is clear. The patient is depressed, and her melancholy interferes with her ability to function. However, during an examination and the chat, the patient is easily distracted (McCutcheon et al, 2020). The patient suffers from anxiety, insomnia, despondency, a sense of worthlessness, anxiousness, delusions, and hallucinations.

HEENT: The patient’s vision and hearing are both in good shape. There is no history of glaucoma or other eye disorders in this patient (Angst & Cassanoy, 2018). The hearing and sense of smell are in good working order. Furthermore, the patient’s dental health is satisfactory, and his throat is free of cancer or sore throat.

SKIN: The patient has no wounds, itches, or bruises.

CARDIOVASCULAR: The patient has no dyspnea, palpitations, or oedema problems.

RESPIRATORY: The patient has a history of bronchitis

GASTROINTESTINAL: The patient has no reflux, abnormal bowel sounds, or abdominal pains.

GENITOURINARY: The patient has had tubal ligation and vulvectomy in the past

HEMATOLOGIC: The patient has no blood disorder, and she has no history of cancer.

LYMPHATICS: The patient has no issues or challenges relating to pain or swelling of the lymph nodes.

ENDOCRINOLOGIC: The patient has not reported any issues of endocrinal challenges.

Objective

Physical Examination: Vitals are as follows: Height 5’11, Weight 247 lbs, BMI 34

Diagnostic Results: Blood and urine tests returned typical results, and the MRI and Ct scan also returned specific results.

Assessment

Mental Status Examination:

The patient is a 54-year-old white female with an age-appropriate look. The patient is aware and cooperative, and she is usually tidy, clean, and well-dressed. There are no abnormalities, and the patient always speaks clearly and coherently (Gordovez, 2020). The patient’s memory, focus, and insight are intact. However, the patient reports a lack of happiness daily over the past two weeks.

Differential Diagnosis:

Bipolar Disorder

Bipolar disorder is a mental condition where a person experiences some hypomanic disorders characterized by increased energy or irritability. They have symptoms alternating between feelings of lows and highs. People who experience bipolar disorder also experience depressive episodes where these people have low moods, and such people tend to isolate themselves from the public. The diagnostic criteria for the condition are the presence of hypomanic episodes. The hypomanic episodes are characterized mainly by inflated self-esteem. The main signs of bipolar disorder are depressive episodes, weight loss and changes in mood swings.

Depression

Depression is a mental health challenge where the individual usually has mental health challenges due to constantly thinking about a particular situation, which makes this person detached from the everyday world. People who suffer from depression tend to have suicidal or homicidal thoughts, which affect the. Some of the common symptoms of depression include changes in sleep patterns, overeating or eating and changes in mood swings. Additionally, people battling depression like staying alone most of the time. The primary diagnostic condition of depression is the changes in mood swings and the hallucinations that one might experience.

Reflections:

The final diagnosis is bipolar disorder. The patient has been treated for bipolar disorder in the past. The final diagnosis for the patient is bipolar disorder. The patient rates her happiness levels as 4 out of 10. The best treatment plan will be using suitable medication and counselling therapy (Carvallo et al, 2020). Non-pharmacological and pharmacological methods must be used to treat bipolar disorder. The pharmacologic treatment will be Fluticasone propionate 50 mg daily and Loratadine 2 mg, Levothyroxine sodium 2 tablets each daily. Cognitive theraphy will also be given to ensure that behavior is corrected. The patient will also be encouraged to adjust to her diet and avoid saturated fat, red meat and simple carbohydrates. Additionally, the patient should be educated on how to stick to the treatment, the possible side effects and how to manage these side effects.

References

Angst, J., & Cassano, G. (2018). The mood spectrum: improving the diagnosis of bipolar disorder. Bipolar disorders7, 4-12.

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine383(1), 58-66.

Gordovez, F. J. A., & McMahon, F. J. (2020). The genetics of bipolar disorder. Molecular psychiatry25(3), 544-559.

Psychopathology

Comprehensive Psychiatric Evaluation

Tina Cherry

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Dr. Clark

April 21, 2022

Comprehensive Psychiatric Evaluation

Subjective

CC (Chief Complaint): Depression

HPI: 54-year-old white female. Individual reports depression has increased. “I been dealing with my boyfriend being in the nursing home. I have no desire to do anything. I just feel depressed and all I do is lay around crying.” Individual reports anxiety the same. She reports Seroquel helps with sleep and denies side effects from medications. Individual rates life 4/10 with 10 being the happiest. She denies SI/HI at this time.

Past Psychiatric History

General Information: The case is a 54-year-old female

Caregivers (If Applicable): The patient does not have a caregiver.

Hospitalizations: Inpatient psychiatric facility within the past 6 months

Medication Trials: No medical trials

Previous Psychiatric Diagnosis: Bipolar Disorder, Anxiety, and Depression

Substance Use and History: No history of substance abuse

Family History: Mother (deceased) cancer, mood disorder

Psychosocial History: Bipolar disorder, depression, and anxiety

Medical History: HTN/ COPD- Bronchitis/Emphysema/ Type II DM/ Hyperlipidemia

Current Medications:

Quetiapine 50 mg, Oxycarbazepine 300 mg, Fluticasone propionate 50 mcg, Loratadine 10 mg, Levothyroxine sodium 50 mcg, Montelukast sod 10 mg, Losartan potassium 50 mg, Novolog 100 units/ml vial; Diltiazem HCL ER coated BEA, VIT D2 1.25 mg (50,000 unit).

Allergies: The patient has no allergy, nor does she have any reaction to certain aspects such as seasonal changes, dust, or pollen.

Reproductive Hx: The patient began her menstrual periods at 15. The patient has no history of reproductive health complications.

Past Medical History: Bronchitis/Emphysema

ROS:

GENERAL: The patient is composed and well-presented. The patient’s speech is clear. The patient is depressed, and her melancholy interferes with her ability to function. However, during an examination and the chat, the patient is easily distracted (McCutcheon et al, 2020). The patient suffers from anxiety, insomnia, despondency, a sense of worthlessness, anxiousness, delusions, and hallucinations.

HEENT: The patient’s vision and hearing are both in good shape. There is no history of glaucoma or other eye disorders in this patient (Angst & Cassanoy, 2018). The hearing and sense of smell are in good working order. Furthermore, the patient’s dental health is satisfactory, and his throat is free of cancer or sore throat.

SKIN: The patient has no wounds, itches, or bruises.

CARDIOVASCULAR: The patient has no dyspnea, palpitations, or oedema problems.

RESPIRATORY: The patient has a history of bronchitis

GASTROINTESTINAL: The patient has no reflux, abnormal bowel sounds, or abdominal pains.

GENITOURINARY: The patient has had tubal ligation and vulvectomy in the past

HEMATOLOGIC: The patient has no blood disorder, and she has no history of cancer.

LYMPHATICS: The patient has no issues or challenges relating to pain or swelling of the lymph nodes.

ENDOCRINOLOGIC: The patient has not reported any issues of endocrinal challenges.

Objective

Physical Examination: Vitals are as follows: Height 5’11, Weight 247 lbs, BMI 34

Diagnostic Results: Blood and urine tests returned typical results, and the MRI and Ct scan also returned specific results.

Assessment

Mental Status Examination:

The patient is a 54-year-old white female with an age-appropriate look. The patient is aware and cooperative, and she is usually tidy, clean, and well-dressed. There are no abnormalities, and the patient always speaks clearly and coherently (Gordovez, 2020). The patient’s memory, focus, and insight are intact. However, the patient reports a lack of happiness daily over the past two weeks.

Differential Diagnosis:

Bipolar Disorder

Bipolar disorder is a mental condition where a person experiences some hypomanic disorders characterized by increased energy or irritability. They have symptoms alternating between feelings of lows and highs. People who experience bipolar disorder also experience depressive episodes where these people have low moods, and such people tend to isolate themselves from the public. The diagnostic criteria for the condition are the presence of hypomanic episodes. The hypomanic episodes are characterized mainly by inflated self-esteem. The main signs of bipolar disorder are depressive episodes, weight loss and changes in mood swings.

Depression

Depression is a mental health challenge where the individual usually has mental health challenges due to constantly thinking about a particular situation, which makes this person detached from the everyday world. People who suffer from depression tend to have suicidal or homicidal thoughts, which affect the. Some of the common symptoms of depression include changes in sleep patterns, overeating or eating and changes in mood swings. Additionally, people battling depression like staying alone most of the time. The primary diagnostic condition of depression is the changes in mood swings and the hallucinations that one might experience.

Reflections:

The final diagnosis is bipolar disorder. The patient has been treated for bipolar disorder in the past. The final diagnosis for the patient is bipolar disorder. The patient rates her happiness levels as 4 out of 10. The best treatment plan will be using suitable medication and counselling therapy (Carvallo et al, 2020). Non-pharmacological and pharmacological methods must be used to treat bipolar disorder. The pharmacologic treatment will be Fluticasone propionate 50 mg daily and Loratadine 2 mg, Levothyroxine sodium 2 tablets each daily. Cognitive theraphy will also be given to ensure that behavior is corrected. The patient will also be encouraged to adjust to her diet and avoid saturated fat, red meat and simple carbohydrates. Additionally, the patient should be educated on how to stick to the treatment, the possible side effects and how to manage these side effects.

References

Angst, J., & Cassano, G. (2018). The mood spectrum: improving the diagnosis of bipolar disorder. Bipolar disorders7, 4-12.

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine383(1), 58-66.

Gordovez, F. J. A., & McMahon, F. J. (2020). The genetics of bipolar disorder. Molecular psychiatry25(3), 544-559.

Psychopathology

Comprehensive Psychiatric Evaluation

Tina Cherry

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Dr. Clark

April 4, 2022

1

7

Subjective

CC: “it works a little too well. It makes me sleepy.”

HPI: The patient is a White female who is 26 years old. She says that she was given medication that made her sleepy during her recent admission to an inpatient psychiatric facility. She says that she was struggling with sleep before she was treated at the facility. She also reports that she was diagnosed with bipolar disorder. She says that within one week, she has lost 14 pounds. She complains that she sleeps too much at night. She rates her happiness in life at an eight out of ten and denies suicide and homicide ideation. The patient reports that she has highs and lows in her moods.

Past Psychiatric History

General Statement: The patient has been previously diagnosed with bipolar disorder.

Caregivers: not reported.

Hospitalizations: Prior inpatient admission at a psychiatric facility.

Medication Trials: Lithium during last inpatient visit

Previous Psychiatric Diagnosis: Bipolar disorder

Substance Use History: The patient does not drink, abuse illicit drugs, and has never smoked.

Family History: Both her parents are alive, and her father has skin cancer that has metastases to the brain.

Psychosocial History: No reported psychosocial history.

Medical History:

Current Medications: Gabapentin 600mg in the morning and noon, and 1200mg at night. Abilify 5mg at night

Allergies: Lithium causes her to have diarrhea.

Reproductive Hx: No reported childern.

Past Medical History: Hyperlipidemia.

ROS:

GENERAL: The patient is alert and well oriented to time, place, and person.

HEENT: The patient does not have any swellings on the head, audio and visual acuity is normal, no sinus infections, and no swollen lymph nodes in the throat.

SKIN: The skin does not have any breakages or rashes. It is also sufficiently moist with normal pigmentation.

CARDIOVASCULAR: The patient does not experience any discomfort in the chest.

RESPIRATORY: The patient has steady breathing and does not experience shortness of breath. The rising and falling of her chest are expected, with no dyspnea or respiratory issues.

GASTROINTESTINAL: The patient does not have any nausea, abdominal pains, running stomach, or vomiting episodes

GENITOURINARY: The patient can pass urine without experiencing any pain or discomfort.

MUSCULOSKELETAL: The patient has a full range of ambulatory movements with no pain in her joints. She moves freely with no constraints or pain.

HEMATOLOGIC: The patient does not have anemia.

LYMPHATICS: There is no splenectomy or swollen lymph nodes present.

ENDOCRINOLOGIC: There are no endocrinal conditions noted or any unusual hormonal changes.

Objective

Physical Examination: Vitals are as follows: Ht: 5’11” Wt: 169 lbs BMI: 23.57 Pain: 0/10

Diagnostic results: Blood and urine tests returned unremarkable results, and the MRI and CT scan also returned unremarkable results.

Assessment

Mental Status Examination

The patient is a 26-year-old White female who is well oriented to time, person, and place. She is cooperative during the examination with clear and coherent speech. She also articulates her thoughts clearly. She does not have any suicidal or homicidal ideations. The patient says that she has experienced hallucinations and delusions. Both her long-term and short-term concentration are good. The patient has experienced hypomania, mania, and depression.

Differential diagnosis

Bipolar I Disorder

Bipolar I disorder is a mental condition where the individual experiences manic or hypomanic episodes characterized by high increases in energy or irritability (McIntyre et al., 2020). Individuals also experience depressive episodes when they have low moods and isolate themselves from people. The diagnostic criteria for the condition involve the presence of manic and hypomanic episodes (McIntyre et al., 2020). The manic episode is characterized by grandiosity and inflated self-esteem, being talkative, flight of thought, and increased psychomotor activity. The depressive episodes are characterized by a persistent depressed mood, lack of interest in activities, considerable weight loss, hypersomnia or insomnia, and psychomotor retardation (McIntyre et al., 2020). The patient displays manic, hypomanic, and depressive episodes. They have also reported significant weight loss. These symptoms are consistent with bipolar I disorder, making it the primary diagnosis.

Schizoaffective Disorder

Schizoaffective disorder is a mental health condition characterized by schizophrenic symptoms, including delusions and hallucinations (Miller & Black, 2019). The state also presents with mood disorder symptoms which include mania and depression. There are two types of schizoaffective disorders, namely depressive type and bipolar type (Miller & Black, 2019). Individuals with the condition will present with delusive behavior such as having fixed and false beliefs that contradict apparent evidence. They will also have visual or auditory hallucinations and bizarre behavior (Miller & Black, 2019). The depressive symptoms will manifest as feelings of emptiness and sadness. The individual will also feel worthless. Individuals with schizoaffective disorder will often have suicide and homicidal ideation (Miller & Black, 2019). The main difference between bipolar I disorder and schizoaffective disorder is the presence of psychosis. The patient, in this case, does not exhibit symptoms of psychosis which rules out schizoaffective disorder.

Major Depressive Disorder

Major depressive disorder is a mental health condition characterized by a relapsing and remitting cycle of depressive episodes (Hasin et al., 2018). The depressive episodes can manifest in a persistently low mood. During depressive moods, the individual will also experience a decrease in their self-attitude, which leads to low confidence and self-esteem. There will also be reduced physical and mental energy. The individual’s low mood may also manifest as hopelessness, self-deprecation, and self-blame (Hasin et al., 2018). Some of the common symptoms of the major depressive disorder include changes in the individual’s sleep patterns, either hypersomnia or insomnia (Hasin et al., 2018). The individual will also have suicidal and homicidal ideations. The presence of psychotic episodes is also another symptom where the individual will have delusions or hallucinations. While both major depressive disorder and bipolar I disorder have overlapping symptoms, the main distinction is that major depressive disorder is unipolar. It means that in major depressive disorder, there are no manic episodes, whereas in bipolar I disorder, there are manic episodes.

Reflections

The patient has been treated for bipolar I disorder in the past. She has been taking Gabapentin and Abilify, but she complains that she sleeps too much. She rates her happiness mood highly, meaning that she must be on a manic episode. Her pharmacological treatment plan will be Gabapentin, one tablet taken twice daily and 1.5 tablets taken at night. She will also be prescribed Aripiprazole 5 mg taken at night. Cognitive-behavioral therapy has been proven to be effective in treating bipolar I disorder (David et al., 2018). Therefore the psychotherapy plan will involve using cognitive-behavioral therapy to improve the patient’s symptoms by modifying her behavior and helping her manage both her manic and depressive episodes. The patient will also be subjected to alternative therapy, including joining support groups for individuals with the same condition. The patient will also be encouraged to adjust their diet and avoid diets rich in saturated fats, red meat, trans fats, and simple carbohydrates (Łojko et al., 2018). The patient should also be educated on how to adhere to their prescriptions, any potential side effects they should anticipate, and when to seek medical advice if the side effects worsen.

References

David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current

gold standard of psychotherapy. Frontiers in psychiatry9, 4.

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018).

Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry75(4), 336-346.

Łojko, D., Stelmach, M., & Suwalska, A. (2018). Is diet important in bipolar disorder?. Psychiatr.

Pol52(5), 783-795.

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., … &

Mansur, R. B. (2020). Bipolar disorders. The Lancet396(10265), 1841-1856.

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of clinical

psychiatry: official journal of the American Academy of Clinical Psychiatrists31(1), 47-53.

Psychopathology

Assignment: Journal Entry

Critical reflection of your growth and development during your practicum experience in a clinical setting has the benefit of helping you to identify opportunities for improvement in your clinical skills, while also recognizing your strengths and successes. 

Use this Journal to reflect on your clinical strengths and opportunities for improvement, the progress you made, and what insights you will carry forward into your next practicum

· Refer to the “Advanced Nursing Practice Competencies and Guidelines” found in the Week 1 Learning Resources, and consider the quality measures or indicators advanced nursing practice nurses must possess in your specialty of interest.

· Refer to your “Clinical Skills Self-Assessment Form” you submitted in Week 1, and consider your strengths and opportunities for improvement.

· Refer to your Patient Log in Meditrek, and consider the patient activities you have experienced in your practicum experience. Reflect on your observations and experiences.

In 450–500 words, address the following:

Learning From Experiences

·  Revisit the goals and objectives from your Practicum Experience Plan. Explain the degree to which you achieved each during the practicum experience.

· Reflect on the three (3) most challenging patients you encountered during the practicum experience. What was most challenging about each?

· What did you learn from this experience?

· What resources did you have available?

· What evidence-based practice did you use for the patients?

· What new skills are you learning?

· What would you do differently?

· How are you managing patient flow and volume? 

Communicating and Feedback

· Reflect on how you might improve your skills and knowledge and how to communicate those efforts to your Preceptor.

· Answer the questions: How am I doing? What is missing?

· Reflect on the formal and informal feedback you received from your Preceptor. 

Psychopathology

Comprehensive Psychiatric Evaluation

Tina Cherry

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Dr. Clark

April 4, 2022

1

7

Subjective

CC: “it works a little too well. It makes me sleepy.”

HPI: The patient is a White female who is 26 years old. She says that she was given medication that made her sleepy during her recent admission to an inpatient psychiatric facility. She says that she was struggling with sleep before she was treated at the facility. She also reports that she was diagnosed with bipolar disorder. She says that within one week, she has lost 14 pounds. She complains that she sleeps too much at night. She rates her happiness in life at an eight out of ten and denies suicide and homicide ideation. The patient reports that she has highs and lows in her moods.

Past Psychiatric History

General Statement: The patient has been previously diagnosed with bipolar disorder.

Caregivers: not reported.

Hospitalizations: Prior inpatient admission at a psychiatric facility.

Medication Trials: Lithium during last inpatient visit

Previous Psychiatric Diagnosis: Bipolar disorder

Substance Use History: The patient does not drink, abuse illicit drugs, and has never smoked.

Family History: Both her parents are alive, and her father has skin cancer that has metastases to the brain.

Psychosocial History: No reported psychosocial history.

Medical History:

Current Medications: Gabapentin 600mg in the morning and noon, and 1200mg at night. Abilify 5mg at night

Allergies: Lithium causes her to have diarrhea.

Reproductive Hx: No reported childern.

Past Medical History: Hyperlipidemia.

ROS:

GENERAL: The patient is alert and well oriented to time, place, and person.

HEENT: The patient does not have any swellings on the head, audio and visual acuity is normal, no sinus infections, and no swollen lymph nodes in the throat.

SKIN: The skin does not have any breakages or rashes. It is also sufficiently moist with normal pigmentation.

CARDIOVASCULAR: The patient does not experience any discomfort in the chest.

RESPIRATORY: The patient has steady breathing and does not experience shortness of breath. The rising and falling of her chest are expected, with no dyspnea or respiratory issues.

GASTROINTESTINAL: The patient does not have any nausea, abdominal pains, running stomach, or vomiting episodes

GENITOURINARY: The patient can pass urine without experiencing any pain or discomfort.

MUSCULOSKELETAL: The patient has a full range of ambulatory movements with no pain in her joints. She moves freely with no constraints or pain.

HEMATOLOGIC: The patient does not have anemia.

LYMPHATICS: There is no splenectomy or swollen lymph nodes present.

ENDOCRINOLOGIC: There are no endocrinal conditions noted or any unusual hormonal changes.

Objective

Physical Examination: Vitals are as follows: Ht: 5’11” Wt: 169 lbs BMI: 23.57 Pain: 0/10

Diagnostic results: Blood and urine tests returned unremarkable results, and the MRI and CT scan also returned unremarkable results.

Assessment

Mental Status Examination

The patient is a 26-year-old White female who is well oriented to time, person, and place. She is cooperative during the examination with clear and coherent speech. She also articulates her thoughts clearly. She does not have any suicidal or homicidal ideations. The patient says that she has experienced hallucinations and delusions. Both her long-term and short-term concentration are good. The patient has experienced hypomania, mania, and depression.

Differential diagnosis

Bipolar I Disorder

Bipolar I disorder is a mental condition where the individual experiences manic or hypomanic episodes characterized by high increases in energy or irritability (McIntyre et al., 2020). Individuals also experience depressive episodes when they have low moods and isolate themselves from people. The diagnostic criteria for the condition involve the presence of manic and hypomanic episodes (McIntyre et al., 2020). The manic episode is characterized by grandiosity and inflated self-esteem, being talkative, flight of thought, and increased psychomotor activity. The depressive episodes are characterized by a persistent depressed mood, lack of interest in activities, considerable weight loss, hypersomnia or insomnia, and psychomotor retardation (McIntyre et al., 2020). The patient displays manic, hypomanic, and depressive episodes. They have also reported significant weight loss. These symptoms are consistent with bipolar I disorder, making it the primary diagnosis.

Schizoaffective Disorder

Schizoaffective disorder is a mental health condition characterized by schizophrenic symptoms, including delusions and hallucinations (Miller & Black, 2019). The state also presents with mood disorder symptoms which include mania and depression. There are two types of schizoaffective disorders, namely depressive type and bipolar type (Miller & Black, 2019). Individuals with the condition will present with delusive behavior such as having fixed and false beliefs that contradict apparent evidence. They will also have visual or auditory hallucinations and bizarre behavior (Miller & Black, 2019). The depressive symptoms will manifest as feelings of emptiness and sadness. The individual will also feel worthless. Individuals with schizoaffective disorder will often have suicide and homicidal ideation (Miller & Black, 2019). The main difference between bipolar I disorder and schizoaffective disorder is the presence of psychosis. The patient, in this case, does not exhibit symptoms of psychosis which rules out schizoaffective disorder.

Major Depressive Disorder

Major depressive disorder is a mental health condition characterized by a relapsing and remitting cycle of depressive episodes (Hasin et al., 2018). The depressive episodes can manifest in a persistently low mood. During depressive moods, the individual will also experience a decrease in their self-attitude, which leads to low confidence and self-esteem. There will also be reduced physical and mental energy. The individual’s low mood may also manifest as hopelessness, self-deprecation, and self-blame (Hasin et al., 2018). Some of the common symptoms of the major depressive disorder include changes in the individual’s sleep patterns, either hypersomnia or insomnia (Hasin et al., 2018). The individual will also have suicidal and homicidal ideations. The presence of psychotic episodes is also another symptom where the individual will have delusions or hallucinations. While both major depressive disorder and bipolar I disorder have overlapping symptoms, the main distinction is that major depressive disorder is unipolar. It means that in major depressive disorder, there are no manic episodes, whereas in bipolar I disorder, there are manic episodes.

Reflections

The patient has been treated for bipolar I disorder in the past. She has been taking Gabapentin and Abilify, but she complains that she sleeps too much. She rates her happiness mood highly, meaning that she must be on a manic episode. Her pharmacological treatment plan will be Gabapentin, one tablet taken twice daily and 1.5 tablets taken at night. She will also be prescribed Aripiprazole 5 mg taken at night. Cognitive-behavioral therapy has been proven to be effective in treating bipolar I disorder (David et al., 2018). Therefore the psychotherapy plan will involve using cognitive-behavioral therapy to improve the patient’s symptoms by modifying her behavior and helping her manage both her manic and depressive episodes. The patient will also be subjected to alternative therapy, including joining support groups for individuals with the same condition. The patient will also be encouraged to adjust their diet and avoid diets rich in saturated fats, red meat, trans fats, and simple carbohydrates (Łojko et al., 2018). The patient should also be educated on how to adhere to their prescriptions, any potential side effects they should anticipate, and when to seek medical advice if the side effects worsen.

References

David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current

gold standard of psychotherapy. Frontiers in psychiatry9, 4.

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018).

Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry75(4), 336-346.

Łojko, D., Stelmach, M., & Suwalska, A. (2018). Is diet important in bipolar disorder?. Psychiatr.

Pol52(5), 783-795.

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., … &

Mansur, R. B. (2020). Bipolar disorders. The Lancet396(10265), 1841-1856.

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of clinical

psychiatry: official journal of the American Academy of Clinical Psychiatrists31(1), 47-53.

Psychopathology

Neurocognitive and Neurodevelopmental Disorders

The human brain only constitutes approximately 2% of an individual’s total body weight, a percentage that pales in comparison to the brain’s level of importance in human development (Koch, 2016). Although externally protected by layers of membranes as well as the skull, the brain is not very resistant to damage. Damage to the brain may compromise its functionality, which may, in turn, lead to neurodevelopmental disorders in childhood and adolescence or neurocognitive disorders for any number of reasons across the lifespan. 

· Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information

· Formulate differential diagnoses using DSM-5 criteria for patients with neurocognitive and neurodevelopmental disorders across the lifespan

Assignment: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

Neurodevelopmental disorders begin in the developmental period of childhood and may continue through adulthood. They may range from the very specific to a general or global impairment, and often co-occur (APA, 2013). They include specific learning and language disorders, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, and intellectual disabilities. Neurocognitive disorders, on the other hand, represent a decline in one or more areas of prior mental function that is significant enough to impact independent functioning. They may occur at any time in life and be caused by factors such brain injury; diseases such as Alzheimer’s, Parkinson’s, or Huntington’s; infection; or stroke, among others.

For this Assignment, you will assess a patient in a case study who presents with a neurocognitive or neurodevelopmental disorder.

· 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.

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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.).

CASE STUDY

Name: Harold Griffin Gender: male Age:58 years old T- 98.8 P- 86 R 18 134/88 Ht 5’11 Wt 180lbs Background: Has bachelor’s degree in engineering. He is homosexual and dates casually, never married, no children. Has one younger sister. Sleeps 4-6 hours, appetite good. Denied legal issues; MOCA 27/30 difficulty with attention and delayed recall; ASRS-5 20/24; denied hx of drug use; enjoys one scotch drink on the weekends with a cigar. Allergies Morphine; history HTN blood pressure controlled with losartan 100mg daily, angina prescribed ASA 81mg po daily, metoprolol 25mg twice daily. Hypertriglyceridemia prescribed fenofibrate 160mg daily, has BPH prescribed tamsulosin 0.4mg po bedtime.

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00:00:00TRANSCRIPT OF VIDEO FILE: 

00:00:00______________________________________________________________________________ 

00:00:00BEGIN TRANSCRIPT: 

00:00:00[sil.] 

00:00:15OFF CAMERA So, you told your supervisor you were having difficulty with concentration, and then it was your supervisor who set up this appointment, right, is it? 

00:00:25HAROLD Yeah, I, I work at this large architectural engineering firm and it’s all great. Except, they’ve accelerated the deadlines now and it just puts a lot of pressure on. And I, I just can’t concentrate. I mean, everyone else is, doesn’t have a problem with it. But, but I just, I just can’t seem to be able to do the same job they’re doing. 

00:00:50OFF CAMERA Okay, tell me about your problem with concentration. 

00:00:55HAROLD Well, um, you know it’s just… Perfect example is, is they wanted me to design um, air ducts. 

00:01:05OFF CAMERA Right. 

00:01:05HAROLD Air ducts, simple. But I designed them through solid wall, a fire wall, and a supporting wall and I didn’t even realize what I was doing. 

00:01:15OFF CAMERA Uh-huh. 

00:01:15HAROLD You know, I mean, um, I’m making silly mistakes like that because, another time we had these windows, we already bought them, design, beautiful, they’re going to be in this entire building. 

00:01:30OFF CAMERA Right. 

00:01:30HAROLD Every floor. Well, I drew the window opening way too small. Now, I mean, if that would have gone ahead, it would have cost millions. I just, it’s, it’s just silly things like that. 

00:01:45OFF CAMERA Uh-huh, is this a new kind of problem for you? 

00:01:45HAROLD Well, I mean, I didn’t seem to have a problem when everything was relaxed, and the deadlines were normal. 

00:01:50OFF CAMERA Right. 

00:01:55HAROLD I could do the job. Everything was fine. But now we’re on these, these ridiculously tight deadlines and, and I just, can’t seem to do it. Everyone else can. It’s, there’s not a problem for them. And I end up like I’m not pulling my weight. 

00:02:10OFF CAMERA Uh-huh. 

00:02:10HAROLD And they think that and it’s true, I’m not. 

00:02:10OFF CAMERA Now did you have these, uh, similar kind of problems back in school? 

00:02:15HAROLD Well, yeah, I mean, in school everyone would go to the library to cram for big exams, so, I mean. 

00:02:20OFF CAMERA Right. 

00:02:20HAROLD That was a normal thing. And, yeah, I’d go but I’d end up looking out the window. Look it’s snowing, oh, it’s spring time. I’ll go for a walk. And, and if someone is whispering in a library well, I have to go to the other side. All my friends could study anywhere. 

00:02:35OFF CAMERA Uh-huh, but, what other kind of difficulties do you seem to have? 

00:02:40HAROLD Well, at the job we have, these uh, lectures, you know. 

00:02:45OFF CAMERA Right. 

00:02:45HAROLD We’d get together, it’s groups. This is the lectures by the chief of the department gets together with all the architects and engineers and he talks about the mission of the day. What we’re trying to work for, our goals. 

00:02:55OFF CAMERA Right. 

00:03:00HAROLD Do I listen? I’m thinking, maybe, my dog needs a bath. Or what am I going to have for lunch? Or, you know, anything other than what he’s saying. 

00:03:05OFF CAMERA Mm-hmm. 

00:03:10HAROLD And because of that, you know, it’s not a good idea. 

00:03:15OFF CAMERA So, so, is it difficult to sit and listen? 

00:03:20HAROLD Yeah, I mean, okay, we were suppose to be designing this other, on top of this penthouse, this, kind of, a patio, party area. 

00:03:30OFF CAMERA Right. 

00:03:30HAROLD And the gutters around it just to make sure everything was very comfortable for everyone. Well, I got up there and I’m designing and the gutters are here, and no, wait a minute, there’s Italian, tile floor. Doesn’t look like it’s tilted the correct way. So I started studying that and there were already two people assigned to study that. To fix that problem, not me. 

00:03:50OFF CAMERA Mm-hmm. 

00:03:55HAROLD I got in a lot of trouble for that one. 

00:03:55OFF CAMERA Do you have any problems organizing? 

00:04:00HAROLD At home or the office? 

00:04:00OFF CAMERA Uh, either. 

00:04:05HAROLD I’m a bit of a mess. I mean, and I’m messy. I will forget my shoes, my socks, my phone, my jacket, I, I can’t find them. I’m not that organized. And I have a calendar. One of my coworkers, actually bought me a calendar to motivate me. 

00:04:20OFF CAMERA Yeah. 

00:04:25HAROLD To get more organized. So, I started writing down all the important dates and events, but then do I ever look at that calendar? No, I don’t. So, it’s a complete waste of time. 

00:04:35OFF CAMERA What about problems paying bills? 

00:04:40HAROLD Bills, I mean, yeah they get paid. After two or three times of the threatening calls or letters. And then I have to pay the penalties. 

00:04:50OFF CAMERA Hmm, what about hyperactivity? 

00:04:50HAROLD You know, I mean, I’m, sometimes I’m a little more uncomfortable in a chair or you know. But I don’t think that’s that big a deal. I mean, I used to be a lot worse. I mean, uh, there was a time when I was in school, I would get marked down for citizenship because I never raised my hand and I talked out of class and, and I just, couldn’t seem to stay focused. But I’m a lot better now. 

00:05:20OFF CAMERA Mm-hmm, were you ever um, treated with medications or behavioral therapies for ADHD? 

00:05:25HAROLD No, no. My mother threatened that one time, but I was never evaluated. Never went, uh, I’m kind of amazed she never just dragged me into a doctor’s office, but she never did. 

00:05:40OFF CAMERA Do you drink any caffeinated drinks? 

00:05:45HAROLD Coffee, soda, you know, once in a while. But when I was a kid, my mother said no caffeine, no sugar, cause you’ll climb the walls. I was already doing it anyway and so she, I uh, once and a while I’ll have a little caffeine now and it kind of helps me focus a little but, sugar, I stay away from that. It’s just not a good idea. 

00:06:05END TRANSCRIPT 

Psychopathology

Neurocognitive and Neurodevelopmental Disorders

The human brain only constitutes approximately 2% of an individual’s total body weight, a percentage that pales in comparison to the brain’s level of importance in human development (Koch, 2016). Although externally protected by layers of membranes as well as the skull, the brain is not very resistant to damage. Damage to the brain may compromise its functionality, which may, in turn, lead to neurodevelopmental disorders in childhood and adolescence or neurocognitive disorders for any number of reasons across the lifespan. 

· Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information

· Formulate differential diagnoses using DSM-5 criteria for patients with neurocognitive and neurodevelopmental disorders across the lifespan

Assignment: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

Neurodevelopmental disorders begin in the developmental period of childhood and may continue through adulthood. They may range from the very specific to a general or global impairment, and often co-occur (APA, 2013). They include specific learning and language disorders, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, and intellectual disabilities. Neurocognitive disorders, on the other hand, represent a decline in one or more areas of prior mental function that is significant enough to impact independent functioning. They may occur at any time in life and be caused by factors such brain injury; diseases such as Alzheimer’s, Parkinson’s, or Huntington’s; infection; or stroke, among others.

For this Assignment, you will assess a patient in a case study who presents with a neurocognitive or neurodevelopmental disorder.

· 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.

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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.).

CASE STUDY

Name: Harold Griffin Gender: male Age:58 years old T- 98.8 P- 86 R 18 134/88 Ht 5’11 Wt 180lbs Background: Has bachelor’s degree in engineering. He is homosexual and dates casually, never married, no children. Has one younger sister. Sleeps 4-6 hours, appetite good. Denied legal issues; MOCA 27/30 difficulty with attention and delayed recall; ASRS-5 20/24; denied hx of drug use; enjoys one scotch drink on the weekends with a cigar. Allergies Morphine; history HTN blood pressure controlled with losartan 100mg daily, angina prescribed ASA 81mg po daily, metoprolol 25mg twice daily. Hypertriglyceridemia prescribed fenofibrate 160mg daily, has BPH prescribed tamsulosin 0.4mg po bedtime.

Search transcript

Translate

00:00:00TRANSCRIPT OF VIDEO FILE: 

00:00:00______________________________________________________________________________ 

00:00:00BEGIN TRANSCRIPT: 

00:00:00[sil.] 

00:00:15OFF CAMERA So, you told your supervisor you were having difficulty with concentration, and then it was your supervisor who set up this appointment, right, is it? 

00:00:25HAROLD Yeah, I, I work at this large architectural engineering firm and it’s all great. Except, they’ve accelerated the deadlines now and it just puts a lot of pressure on. And I, I just can’t concentrate. I mean, everyone else is, doesn’t have a problem with it. But, but I just, I just can’t seem to be able to do the same job they’re doing. 

00:00:50OFF CAMERA Okay, tell me about your problem with concentration. 

00:00:55HAROLD Well, um, you know it’s just… Perfect example is, is they wanted me to design um, air ducts. 

00:01:05OFF CAMERA Right. 

00:01:05HAROLD Air ducts, simple. But I designed them through solid wall, a fire wall, and a supporting wall and I didn’t even realize what I was doing. 

00:01:15OFF CAMERA Uh-huh. 

00:01:15HAROLD You know, I mean, um, I’m making silly mistakes like that because, another time we had these windows, we already bought them, design, beautiful, they’re going to be in this entire building. 

00:01:30OFF CAMERA Right. 

00:01:30HAROLD Every floor. Well, I drew the window opening way too small. Now, I mean, if that would have gone ahead, it would have cost millions. I just, it’s, it’s just silly things like that. 

00:01:45OFF CAMERA Uh-huh, is this a new kind of problem for you? 

00:01:45HAROLD Well, I mean, I didn’t seem to have a problem when everything was relaxed, and the deadlines were normal. 

00:01:50OFF CAMERA Right. 

00:01:55HAROLD I could do the job. Everything was fine. But now we’re on these, these ridiculously tight deadlines and, and I just, can’t seem to do it. Everyone else can. It’s, there’s not a problem for them. And I end up like I’m not pulling my weight. 

00:02:10OFF CAMERA Uh-huh. 

00:02:10HAROLD And they think that and it’s true, I’m not. 

00:02:10OFF CAMERA Now did you have these, uh, similar kind of problems back in school? 

00:02:15HAROLD Well, yeah, I mean, in school everyone would go to the library to cram for big exams, so, I mean. 

00:02:20OFF CAMERA Right. 

00:02:20HAROLD That was a normal thing. And, yeah, I’d go but I’d end up looking out the window. Look it’s snowing, oh, it’s spring time. I’ll go for a walk. And, and if someone is whispering in a library well, I have to go to the other side. All my friends could study anywhere. 

00:02:35OFF CAMERA Uh-huh, but, what other kind of difficulties do you seem to have? 

00:02:40HAROLD Well, at the job we have, these uh, lectures, you know. 

00:02:45OFF CAMERA Right. 

00:02:45HAROLD We’d get together, it’s groups. This is the lectures by the chief of the department gets together with all the architects and engineers and he talks about the mission of the day. What we’re trying to work for, our goals. 

00:02:55OFF CAMERA Right. 

00:03:00HAROLD Do I listen? I’m thinking, maybe, my dog needs a bath. Or what am I going to have for lunch? Or, you know, anything other than what he’s saying. 

00:03:05OFF CAMERA Mm-hmm. 

00:03:10HAROLD And because of that, you know, it’s not a good idea. 

00:03:15OFF CAMERA So, so, is it difficult to sit and listen? 

00:03:20HAROLD Yeah, I mean, okay, we were suppose to be designing this other, on top of this penthouse, this, kind of, a patio, party area. 

00:03:30OFF CAMERA Right. 

00:03:30HAROLD And the gutters around it just to make sure everything was very comfortable for everyone. Well, I got up there and I’m designing and the gutters are here, and no, wait a minute, there’s Italian, tile floor. Doesn’t look like it’s tilted the correct way. So I started studying that and there were already two people assigned to study that. To fix that problem, not me. 

00:03:50OFF CAMERA Mm-hmm. 

00:03:55HAROLD I got in a lot of trouble for that one. 

00:03:55OFF CAMERA Do you have any problems organizing? 

00:04:00HAROLD At home or the office? 

00:04:00OFF CAMERA Uh, either. 

00:04:05HAROLD I’m a bit of a mess. I mean, and I’m messy. I will forget my shoes, my socks, my phone, my jacket, I, I can’t find them. I’m not that organized. And I have a calendar. One of my coworkers, actually bought me a calendar to motivate me. 

00:04:20OFF CAMERA Yeah. 

00:04:25HAROLD To get more organized. So, I started writing down all the important dates and events, but then do I ever look at that calendar? No, I don’t. So, it’s a complete waste of time. 

00:04:35OFF CAMERA What about problems paying bills? 

00:04:40HAROLD Bills, I mean, yeah they get paid. After two or three times of the threatening calls or letters. And then I have to pay the penalties. 

00:04:50OFF CAMERA Hmm, what about hyperactivity? 

00:04:50HAROLD You know, I mean, I’m, sometimes I’m a little more uncomfortable in a chair or you know. But I don’t think that’s that big a deal. I mean, I used to be a lot worse. I mean, uh, there was a time when I was in school, I would get marked down for citizenship because I never raised my hand and I talked out of class and, and I just, couldn’t seem to stay focused. But I’m a lot better now. 

00:05:20OFF CAMERA Mm-hmm, were you ever um, treated with medications or behavioral therapies for ADHD? 

00:05:25HAROLD No, no. My mother threatened that one time, but I was never evaluated. Never went, uh, I’m kind of amazed she never just dragged me into a doctor’s office, but she never did. 

00:05:40OFF CAMERA Do you drink any caffeinated drinks? 

00:05:45HAROLD Coffee, soda, you know, once in a while. But when I was a kid, my mother said no caffeine, no sugar, cause you’ll climb the walls. I was already doing it anyway and so she, I uh, once and a while I’ll have a little caffeine now and it kind of helps me focus a little but, sugar, I stay away from that. It’s just not a good idea. 

00:06:05END TRANSCRIPT