Psychiatric Evaluation Case Study

Psychiatric Evaluation Case Study

IDENTIFICATION: The patient is a 78-year-old female in general good health living in an assisted living facility. She is a retired executive secretary.

CHIEF COMPLAINT: “Every once in awhile, I see my dead mother laying on the bed, I get scared and run out of the room and get a staff member to come in here. I’m so embarrassed because nothing is in the bed when I return. This happens a lot and sometimes I see people I never met before standing in my kitchen. I get scared, and they disappear.”

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HISTORY OF CHIEF COMPLAINT: The patient was referred for a psychiatric evaluation following the incidents described in the Chief Complaint, which began 3 months ago with abrupt onset. These incidents did not occur while sleeping or waking up from sleep.

PAST PSYCHIATRIC HISTORY: No history of mental illness. Denied any symptoms of mental illness other than the information described earlier.

MEDICAL HISTORY: Her vital signs were normal following the hallucinatory events, that is, pulse 90, BP 130/88. A medical consultation was ordered. The primary care provider ordered an electroencephalogram (EEG)/MRI of the brain to r/o seizures, brain tumors, or encephalopathy, and the results were within normal limits (WNLs) other than periventricular white matter changes associated with age. Comprehensive metabolic panel (CMP), urinalysis (UA), thyroid-stimulating hormone (TSH), triiodothyronine (T³), thyroxine (T⁴), B¹², RBC folate, RPR, and complete blood count (CBC) were all normal. A 48-hour Holter monitor was also ordered. Immediately before her hallucinatory events, distinct episodes of bradycardia of 30 beats/minutes were identified. This cardiac insufficiency would likely contribute to hypoxia. Due to the bradycardia identified with the 48-hour monitor, a pacemaker was inserted. Taking cholesterol medication atorvastatin once a day for several years with normal cholesterol for past 2 years. Taking aspirin 81 mg daily. Psychiatric Evaluation Case Study

HISTORY OF DRUG OR ALCOHOL ABUSE: Denied.

FAMILY HISTORY: Enjoyed living in the assisted living for the past 3 years, had many friends, family visited often, she went to church every Sunday and was well liked.

PERSONAL HISTORY

Perinatal: No known complications.

Childhood: Developmental milestones achieved WNL.

Adolescence: She was on the honor roll in high school and attended 2 years of college for secretarial training with an all A average.

Adulthood: She worked as an executive secretary for an auto company for 30 years until her retirement 10 years ago. After the death of her husband of 50 years, she moved to the assisted living facility about 5 years ago. She said that taking care of the house had become too much of a responsibility for her. She has three children and five grandchildren and is “close” with all of them. They visit often. Her apartment at the assisted living facility is neat and clean and well furnished. Psychiatric Evaluation Case Study

TRAUMA/ABUSE HISTORY: Denied.

MENTAL STATUS EXAMINATION

Appearance: Well dressed, attractive, with weight in proportion to height. She smiles easily.

Behavior and psychomotor activity: Cooperative. Good eye contact. No abnormal movements.

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Formulating the Diagnosis

• Which diagnosis (or diagnoses) should be considered? (Provide at least 2 Dx.),
• What is the rationale for each diagnosis?,
• What test or tools should be considered to help identify the correct diagnosis?,
• What differential diagnoses should be considered?,

Formulating the Treatment Strategy

• What treatment would you prescribe and what is the rationale?,

• • Pharmacology

• • Diagnostic Tests

• • Referrals

• • Psychoeducation

• What standard guidelines would you use to treat or assess this client?

Provide references to support your answers. (minimum of 3)

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