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College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

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Assignment Due Date

 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Subjective:

Video: Training Title 9

Patient details: Ms. Fatima Branning, a 28 year-old African-American female.

CC (chief complaint): Mr. Nehring suggested that Ms. Fatima to go and see the
psychiatrist because she was having some difficulties at work.

HPI: Mr. Nehring suggestsed that Ms. Fatima should go see a psychiatrist because she
was having some difficulties at work. However, the patient believes that Mr. Nehring
wants to fire her because she Eric, her supervisor, is in love with her and that this is
geeting in the way. She however denies that she is not in a relationship with Eric,
claiming that Eric has his own girlfriend and she has her own boyfriend. She believes
that Eric and Mr. Nehring have been ganging up against her. She reports that Eric is
lustful for her because. She however reports that Eric has not done anything
inappropriate. She claims that Eric is lustful for her because he gives her the easiest
assignments to do and he asks her to voice her opinions a lot in their weekely meetings,
and that she is also beautiful. She claims that Mr. Nehring feels threatened by this
situation, hence the need to fire her. She also believes that Mr. Nehring thinks that she
could replace him in a couple of years. She however denies any instances of sexual
harrassments from Eric. However, Mr. Nehrings side of the story is that Ms. Fatima has
not made any sale in three weeks. She claims that her job has affected her health, and
keeps getting worse. She also believes that she is being discriminated at work.She
claims to be having pain in her neck, and this pain has been radiating to her back. She
also reports that there is a lump in her neck, and she is worried that it might be a
cancer. She believes that the cause of the lump is her pain, suffering, and being
heartbroken. She however has not consulted a doctor yet. She believes that all this is
because of Mr. Nehring and Eric.

Past Psychiatric History:

 General Statement: Patient declined to discuss her past psychiatric history.

 Caregivers (if applicable): She was raised by her parents, but she now lives
alone and has no caregiver.
 Hospitalizations: Patient declined to discuss her past psychiatric history.
 Medication trials: Patient has not been on any psychiatric medication trials.
 Psychotherapy or Previous Psychiatric Diagnosis: Patient has no previous
psychiatric diagnosis.

Substance Current Use and History: Patient is not under any substances. There is no
history of substance use.

Family Psychiatric/Substance Use History: She denies any family mental health
issues.

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Psychosocial History: Patient lives in Coronado, CA. She was raised by her parents.
She is their only child. She works as an administrative assistance in car sales. She
holds a bachelor’s degree in hospitality. She currently has a boyfriend.

Medical History: She has a history of scoliosis.

 Current Medications: She is currently managing her scoliosis with chiropractic

care.
 Allergies: Patient is allergic to latex.
 Reproductive Hx: Patients menses are regular. She does not use any birth
control method.

ROS:

 GENERAL: Patient denies weight gain or loss, she is afebrile, no weakness or

fatigue.
 HEENT: Patient has no visual loss, no blurring of vision, no double vision, no
yellowing of sclerae. Ears, Nose, Throat: Patient has no hearing loss, no ear
discharge, no sneezing, no congestion, no runny nose, and no sore throat.
 SKIN: Patient has no rash or itching of the skin.
 CARDIOVASCULAR: Patient has no chest pain, no palpitations, no chest
discomfort, no easy fatiguability on exertion, no chest pressure, no swelling of
lower limbs.
 RESPIRATORY: Patient has no cough, no chest pain, no shortness of breath, no
wheeze, no sputum production.
 GASTROINTESTINAL: Patient has no diarrhea, no constipation, no abdominal
pain, no anorexia, no nausea, no vomiting.
 GENITOURINARY: no pain on urination, no urgency, no burning on urination, no
hesitancy, no odd color of urine.
 All other systems are unremarkable.

Objective:

Vitals: T- 98.4 P- 82 R 18 124/74 Ht 5’0 Wt 118lbs

Physical exam: General exam: On examination, the patient is a middle-aged African-

American lady seated upright. She is in a fair general condition and is of good nutritional
status. She is assertive with her delusions. She has no sclerodermal jaundice, no
conjunctival pallor, no obvious swelling, and no signs of dehydration. She is well
dressed and neat with her hair well kempt.

Diagnostic results: This is a new patient and has not yet been subjected to any
diagnostic tests.

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Assessment:

Mental Status Examination: On examination, the patient is awake, alert, and well-
oriented to place, person, and time. She is well-kempt and dressed appropriately for
age, weather, and occasion. Her appearance is congruent with her age. She is able to
maintain eye contact throughtout the conversation. Her speech is coherent, audible, of
normal rhythm and volume. She is cooperative and fidgety. Her mood appears to be
anxious and her affect is congruent with her mood. Her thought processes are linear,
goal-directed, but delusional. She is able to concentrate and participate in the
conversation as expected.

Differential Diagnoses:
a) Schizophrenia - A complicated, long-lasting mental health condition called
schizophrenia is characterized by a wide range of symptoms, such as
hallucinations, delusions, disordered speech or behavior, and cognitive
impairment. For many patients and their families, the illness is a debilitating
disorder because of its early start and chronic nature. Negative symptoms
(marked by loss or deficits) and cognitive symptoms, such as deficiencies in
attention, working memory, or executive function, frequently combine to cause
disability. Additionally, positive symptoms including suspicion, delusions, and
hallucinations might lead to relapse (Kern & Keedy, 2020). The diagnostic
criteria, etiology, and pathophysiology of schizophrenia have not been agreed
upon due to the disorder's intrinsic variability. According to DSM-5, the diagnosis
of schizophrenia is made if the patient meets atleast two of the following
symptoms: Delusions, hallucinations, disorganized or incoherent speech,
disorganized or unusual movements, or negative symptoms. Negative symptoms
refer to a decline in some certain behaviors. Some patients with negative
symptoms lack the motivation to carry out their daily activities. They may be
having avoliation i.e. a total lack of motivation and this makes it hard for them to
do anything. For this case, the patient meets two of the stated symptoms. To
start with, she is experiencing delusions. This is because she believes that Mr.
Nehring wants to fire her because she is having a relationship with Eric. This
however appears to be untrue as Mr. Nehring claims that she has not made any
sale in three weeks, and this could be a good reason to fire an employee as it
might be a sign of laziness or not being committed to your work. The patient also
believes that the lump she has is a cancer that is as a result of being
heartbroken. This is false since a heartbreak cannot cause a cancerous growth.
Secondly, the patient has negative symptoms i.e. avoliation. As defined above, it
is a total lack of motivation to get any work done. This may be the case since she
has not made any sale in three weeks. This may be as a result of lack of
motivation to perform her duties.
b) Schizoaffective disorder – This condition is identified by a combination of
severe affective and psychotic symptoms (Miller et al., 2019). According to the
Diagnostic and statistical manual of mental disorders (DSM) diagnosis,
schizophrenia symptoms must be present at the same time as mood symptoms
(depression or mania) and must endure for a significant portion of a month.

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Bipolar type (where manic symptoms are prevalent; significant depression

episodes may also occur) or depressive type are further classifications for
schizoaffective disorder (when only schizophrenia and major depressive
symptoms have been present). It is a combination of schizophrenia and mood
disorder (Saadabadi et al., 2019). According to DSM-5, the patient must have at
least two symptoms of schizophrenia and at the same time have mood
symptoms for the diagnosis of schizoaffective disorder to be made. In this case,
the patient demonstrates no mood symptoms, hence ruling out schizoaffective
disorder.
c) Bipolar disorder – This is a differential diagnosis because I think the patient
may be experiencing some form of major depressive episodes because she
believes that Mr. Nehring wants to fire her. A mix of manic (bipolar mania),
hypomanic, and depressed (bipolar depression) episodes, as well as significant
subsyndromal symptoms that frequently appear in between major mood
episodes, describe bipolar affective disorder, a chronic and complicated illness of
mood (Carvalho et al., 2020). It is one of the leading causes of disability around
the globe. Bipolar 1 disease has frequently been linked to severe medical and
mental comorbidity, early death, significant functional impairment, and reduced
quality of life. However, the patient has not exhibited any manic symptoms hence
ruling this as a diagnosis.

Reflections: If I was to assess this patient again, I would utilize some of the
schizophrenia screening tools that are available. Some of the screening tools include
the Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression-
Schizophrenia (CGI-SCH). These tools would help me to confirm my diagnosis and to
rule out other illnesses (Opler et al., 2017). I would also like to have a word with Mr.
Nehring to understand what exactly is going on between the two. Speaking to Eric is
also important to understand what is going on between him and Ms. Fatima. This would
help me to know if what the patient claims is true or if it’s just a delusion. I would also try
to convince her to allow me to speak to her parents about her condition since they
would provide some information that might be useful in my diagnosis.

References

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of

Medicine, 383(1), 58-66.

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

psychiatry: official journal of the American Academy of Clinical Psychiatrists,

31(1), 47-53.

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Opler, M. G., Yavorsky, C., & Daniel, D. G. (2017). Positive and negative syndrome

scale (PANSS) training: challenges, solutions, and future directions. Innovations

in clinical neuroscience, 14(11-12), 77.

Wy, T. J. P., & Saadabadi, A. (2019). Schizoaffective Disorder.

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