Comprehensive Psychiatric Interview
The following paper aims to display and discuss the results of a comprehensive
psychiatric evaluation. The paper is
... [Show More] the assessment of a 19-year-old male hospitalized due to a
recent manic episode. The patient has a three-year history of treatment on and off for mood
disorder. This paper includes the psychiatric assessment, diagnostic and labs conducted, and
differential diagnosis that applies to the current patient situation. The paper concludes with
reflections from the writer regarding the evaluation and what could have been done better.
Interview
Referral Source: Unknown.
- It would be essential to find out who else has been treating him. Does he have a PCP or a
mental health provider?
Historian: Self, accurate historian.
Religion: It would be essential to know what religion he was as it may affect his views on his
illness and the recommended course of treatment.
CC (chief complaint): “I have a bit of a head cold.” “I have just not been myself.” The patient is
vague and does not explicitly state why he is being examined.
HPI: The patient is a 19-year-old Caucasian male with a mood disorder history that began at age
fifteen. He had one prior hospitalization (three days) a year ago. At that time, he was found
wandering on the highway. Mr. L refused medication at the time due to his prior experience with
adverse side effects. He signed himself out of the hospital against medical advice. He has
recently been inappropriate with female neighbors and in public places by yelling sexual
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comments and pulling his pants down. He was admitted one week ago. His mother states that he
had only slept 2-3 hours before admission in the past week. She states that he has been spending
much money on video games and much time playing those games. The patient has indicated that
he is writing a book on how others can be video game masters.
Past Psychiatric History:
General statement: 19-year-old Caucasian male presenting with manic symptoms. The patient
has had a prior manic episode with hospitalization. The patient is currently inpatient and has
been started on Lithium and risperidone.
Caregivers: The patient lives with his sister and both parents.
Hospitalizations: Prior inpatient psychiatric hospitalization over a year ago. The patient refused
medications and signed out AMA. No prior suicide attempts.
- I would want to know what kind of outpatient treatment, if any, he has received.
Medications trials: The patient has previously tried Depakote and Olanzapine on and off. He
stopped medication due to the adverse effects of weight gain.
- It would be essential to know each medication’s dosage, how he was taking, and how
long he took it. Previous history shows the patient’s potential for compliance or noncompliance. It would be essential to know what response the patient had to previous
medications and if the response was positive despite the side effects. The patient’s
past medication trials will guide what the PMHNP prescribes in the current situation
(Ruiz et al., 2015).
Psychotherapy or previous psychiatric diagnosis: Not available.
- The PMHNP would benefit from knowing what prior diagnoses were made and who
made them. While the PMHNP should not simply copy a prior diagnosis, it can help
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guide her in making a current diagnosis (Ruiz et al., 2015). It is essential to know
what modalities of treatment the patient has tried previously. If a medication was the
only prior choice, the PMHNP might want to recommend and try psychotherapy.
Substance Current Use and History: The patient denies any recent alcohol or substance use.
Family Psychiatric/Substance Use History: Father has a history of Bipolar disorder. No family
history of self-harm or suicide.
- It would be essential to know what type of Bipolar the father had and if and how he
was treated. A vital component of the family hx is the response to medication and
treatment. Research shows there is a familial response to medicines, so knowing what
worked and didn’t work for the father will help guide treatment options for the patient
(Ruiz et al., 2015)... [Show Less]