Please reply to the Psychiatric evaluation posted below. Please look at Discussion post
grading rubric. Please use at least two references APA style within the last 6 years.
Psychiatric Evaluation #1
Name: M.A
DOB: 3.18.1968
Primary code: 99214
Ethnicity: Caucasian
Gender: Female
Marital Status: Married
Sources of information: patient and chart review
Subjective:
CC: “Follow-up visit for medication refills”
HPI: Ms. M.A is a 56-year-old female patient that presents via video conference for a follow-up visit. Since her last visit she reports “doing well”. She is taking her sertraline 100mg a day as prescribed with no reported side effects. She does communicate some additional stressors onset her since last visit a month ago. 2 of her grown children have moved back home and her stepdaughter is having some mental health issues which has increased her anxiety. She feels that although her anxiety is higher than normal, she feels that she can use coping skills to alleviate her symptoms and manage her anxiety. Patient is alert and denies headache and dizziness. Patient reports no history or current chest pain or palpitations. Patient negative for any neuromuscular symptoms, SOB, cough, congestion or recent illness. Patient wear glasses for reading and states no hearing issues or ringing of the ear. Patient denies any abnormal symptoms related to GI or GU at this time. She reports no medical concerns and sees PCP regularly. She reports some days feelings of guilt, difficulty concentrating, feeling anxious, becoming easily annoyed or irritable. She denies distractibility, impulsivity, grandiosity, flight of ideas, activity increase, spending/sexual indiscretion, increased talkativeness, feeling depressed, loss of interest, trouble sleeping, decreased energy, change in appetite, psychomotor slowness, suicidal ideations, being unable to control worrying, worrying about many things, trouble relaxing, feeling restless, feeling afraid that something awful might happen, panic attacks and hallucinations. She reports sleeping 7-8 hours per night and denies nightmares. She reports feeling rested upon awakening. She reports a good appetite. She reports 1-2 cups of coffee a day for caffeine intake. She denies tobacco, narcotic and steroid use. She reports 3-4 days a week a couple glasses of wine and CBD gummies a couple times a month. She reports that she is not seeing a counselor or therapist currently. She rates her mood at 8 out of 10, with 10 being the best.
Past Psychiatric History: General Anxiety Disorder (made by previous psychiatrist), no other diagnoses. No inpatient psychiatric hospitalizations, suicide attempts or psychotherapy. Psychotherapy recommended and patient not agreeable at this time.
Previous Psychiatric Medications: Lexapro- caused decrease libido unknown length of time (pt states a couple of months and unknown dosing), Viibryd-caused increase anxiety, used for a month and doesn’t remember dosing.
Current Medications: sertraline 100mg PO daily, lisinopril-hydrochlorothiazide 20-12.5mg po daily, rosuvastatin 10 mg po daily.
Substance use/Addictive behaviors: No history of substance abuse, illicit drugs, gambling, excessive spending, sexual indiscretions or excessive ETOH.
Family Psychiatric History: No familial history reported.
Medical History:
Allergies: NKDA
Surgeries: sinus, 2 C-sections
Illnesses: hypertension, hypercholesterolemia
Past Illnesses: Endometritis w/ precancerous cells (total hysterectomy 11/1/2023)
Lab Results: none, sees primary provider regularly, no additional labs needed.
Development/Psychosocial: Patient has a 4-year degree, works as a recruiter. Reports a strong supportive social network. The patient is married. 2 adult biological children, 1 stepdaughter. Reports great childhood. Denies any legal issues or history of previous or current abuse. Denies strong religious background.
Assets/Stressors: 2 adult children recently moved back home with her. Stepdaughter having mental health issues that patient and husband attempting to help family member with.
Objective:
MSE:
The patient is a Caucasian female who is A/Ox 4, appropriately dressed in attire and for the current weather She has adequate grooming and hygiene. She is cooperative with a good attitude, good eye contact, normal psychomotor activity. She shows no signs of agitation, tremors or involuntary movements. Her behavior and affect are appropriate for her age and situation. She is attentive to the interviewer and engages in the conversation. Her speech is of a normal rate, amplitude and prosody. She can comprehend questions and articulates her needs and ask pertinent questions to the topic. Her thought process is organized, logical and linear. There are no signs of thought blocking, rambling or repetition of words, sentences, ideas or topics. No abnormal thought content. Patient denies delusions, hallucinations, phobias, SI or HI. She possesses full insight and good judgment with recent and remote memory intake.
Physical Exam: Differed due to tele-health visit
Differential: Adjustment Disorder. This is only diagnosed when all other disorders are ruled out. In these diagnoses, the patient has symptoms of anxiety as a response to a known stressor within the first 3 months of exposure to the stressor. The anxiety does not remain longer than 6 months after the stressor has resolved, as well as any side effects of the stressor (Association, 2013).
Diagnostic Impression w/ Formulation: General Anxiety disorder. Patient had symptoms of irritability, general worrying about work and mainly family issues most of her life but with an increase in intensity since her mother received a terminal diagnosis and was placed on hospice. The patient self-reports that she continues to struggle with coping when uncontrollable situations arise. When symptoms are not present worrying that something else might occur still resonates in her. She feels restless and does not possess the ability to sit still. She reports her feelings over her life as an anxiousness or nervousness feeling. General anxiety disorder follows these symptoms with a period of consistency of 6 months (Mishra & Varma, 2023). While the patient has been able to manage her anxiety previously, Life events, external factors and familial health concerns have led her anxiety spinning out of control, leading her to seek out medical assistance to manage her symptoms. The patient does not report any symptoms of depression, hopelessness, sleep disturbances, change in energy, suicidal thought, concentration issues, appetite or weight changes or any other symptoms that lead you to think that the patient could be experiencing any signs or symptoms of depression stemming from her mother’s prognosis stemming from stress (Haehner et al., 2024).
Risk Assessment: Patient denies drug abuse or use. Patient denies SI/HI or history of. Patient makes plans for future as appropriate. Patient does not show or verbalize any signs or symptoms of violence, impulsivity, hallucinations, depression or self-inflicted behavior. Patient verbalizes hope for the future, has responsibilities to kids and family and takes steps to engage in treatment.
Recommendation and Plan with goals and rationales with Neurobiology:
Goals: Reduce the overall intensity and frequency of the anxiety. Increase the ability to function daily. Resolve the core issue that is causing the anxiety. Develop coping skills to better handle the anxieties encountered in the future. The patient needs to exam why she is anxious regarding her 2 children moving home. Are they messy? Increase cost of utilities or groceries? Does she feel responsible to managing their day-to-day activities or life choices. The patient needs to adopt healthy boundaries regarding sharing of household responsibilities, participation in bill pay or alleviating burden of additional cost. Setting a timeframe for moving back. Developing a timeline, allows the patient and family members to have end goals. This allows the children to have a deadline to progressing through life and the patient an understanding that this is temporary. A verbal understanding allows the patient to release the pressure taking on the responsibility of their decisions (Dziegielewski, 2014).
Medications: Continue Sertraline 100mg PO daily. Sertraline is shown to help with anxiety especially social which is the highlighted trigger for the core issue of that patient’s anxiety and stressors. Sertraline is an SSRI and works on blocking serotonin. This medication has been shown to increase suicidal ideation and patient must be screened for this. This medication is not recommended in younger adults or older adults. The patient is screened at every visit and contracts for safety. Patient verbalizes no SI thoughts to immediately call the office. Patient understands that this medication should not be stopped abruptly due to serotonin syndrome. The patient is not on any medications that are contraindicated. She also has no disease processes that would interfere or lead to toxicity at this time. The patient gets regular blood work through her PCP. SRI’s block serotonin transports by specific selection back into the neuron, this leads to recycling, increasing 5-HT. These changes cause a downstream rippling effect thought to alleviate the effects of anxiety and depression (Melaragno, 2021).
Cognitive Behavioral Therapy: first-line treatment for anxiety disorders. This aims at targeting a patient’s experiences and the circumstances that surround the situations by using adaptive and realistic thinking patterns that help the patient avoid the traps that anxiety plays on a patient’s way of thinking. The plan to change the cognitive way of thinking alleviates the overthinking or the constant thinking that gives way to negative thoughts and over analyzation, allowing the patient to think in less extremes (Curtiss et al., 2021).
Follow-up: In 1 month. With the increase stress, the patient needs an evaluation of coping skills and symptoms management needs to ensure safety.
References
Association, A. P. (2013). Diagnostic and statistical manual of mental disorders, 5th edition: Dsm-5 (5th ed.). American Psychiatric Publishing.
Curtiss, J. E., Levine, D. S., Ander, I., & Baker, A. W. (2021). Cognitive-behavioral treatments for anxiety and stress-related disorders. FOCUS, 19(2), 184–189. https://doi.org/10.1176/appi.focus.20200045
Dziegielewski, S. F. (2014). Dsm-5 in action (3rd ed.). Wiley.
Haehner, P., Würtz, F., Kritzler, S., Kunna, M., Luhmann, M., & Woud, M. L. (2024). The relationship between the perception of major life events and depression: A systematic scoping review and meta-analysis. Journal of Affective Disorders, 349, 145–157. https://doi.org/10.1016/j.jad.2024.01.042
Melaragno, A. J. (2021). Pharmacotherapy for anxiety disorders: From first-line options to treatment resistance. FOCUS, 19(2), 145–160. Retrieved June 14, 2023, from https://doi.org/10.1176/appi.focus.20200048
Mishra, A. K., & Varma, A. R. (2023). A comprehensive review of the generalized anxiety disorder. Cureus. https://doi.org/10.7759/cureus.46115
