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Week #2-Comprehensive Psychiatric Evaluation
Michelle Cicala
Walden University
NRNP 6645
Dr. Lavon Williams
December 13, 2021
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Week #2-Comprehensive Psychiatric Evaluation
Chief complaint – Pattie is Mom of 5 children. One child was left behind, her daughter
who was eight years old at that time Just two years back, finally, they could get her visa, and she
brought her to the United States. Patti’s daughter is now 21 years old. Her name is Shireen, and
she causes chaos inside the household. She stated her father sexually and physically abused her.
There is constant fighting, screaming, and yelling in the home. Patti suffers from sadness and
depression because she is in pain and unable to control the pain. She relies on children.
Culturally, she expects her children to stay home and take care of her. Sibling ages
24;23;21;18;15
History of present illness (HPI): Patti is a 40-year-old Iranian-born female and presents
for family psychotherapy sessions. Patti reports feeling hopeless, lonely, depressed, and in
constant pain. She has had past surgeries with no relief from pain. The Patient is not on
medication. She expects her 23-year-old daughter, Sharlene, to come to take care of her. She
wants her daughter to visit her and sleep over. The daughter is uncomfortable with the dogs in
the house (Mother and Daughter, 2003).
The Patient was on a Medical Visa to go to the United States. She decided to stay in the
US but unable to get her 8-year daughter here until two years ago. Shireen claimed her father
has sexually and physically abused her. Patti reported Shireen had one counseling session and
refused to go back. She wants to work and make money. Patti call husband asked about abuse.
Husband yelling at Patti, so she stopped talking to him. The family has stopped speaking to
Father. Father is now on 3rd wife in 2 years. Shireen ran off and got married, and she is no longer
living with Mom. The patient is happy she is gone because the house is quite now (Mother and
Daughter, 2003).
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Patti is disabled and is in constant pain. She cannot take care of herself, and she feels
depressed, lonely and hopeless. Patti has strained relationships with her children, she has
unrealistic expectations of her children. Sharlene, 23 years old, is speaking for all the children,
and they want her to take care of herself and be independent. The Patient had a Medical Visa to
go to the United States. She decided to stay in the US. She was unable to get her daughter here
until two years ago. The family stopped speaking to Father. He is now in his 3rd marriage.
Past Psychiatric History-No past psychiatric history
Substance Use History-No past substance use
Medication Trials and Current Medications-No medication trials
Psychotherapy or previous psychiatric diagnosis-None
Family Psychiatric/Substance use, Social, and Medical history- Husband is abusive
physically and mentally to the Patient, then the Patient moved to the United States
without a spouse. She took 4 of 5 children. The father/husband was sexually and
physically abused; his daughter was l left behind since she was eight years old.
The daughter migrated to the US 2 years ago to join the Patient and other
siblings.
Psychosocial history/Developmental history-Patient met all developmental milestones.
Her husband was abusive to her physically and mentally. Patient wants her children to take
emotionally and physically take care of her.
Medical history-Chronic pain; 2 past surgical interventions
Allergies-NKA
ROS
GENERAL: Generalized obesity, reports of fatigue and weakness, and constant pain.
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HEENT: Head: no open sores Eyes: no blurred vision, complex vision. Ears-
symmetrical, WNL Neck: WNL-Throat: denies difficulty swallowing, WNL.
SKIN: Denies rashes, bruises, or lesions
CARDIOVASCULAR: Denies chest pain, tachycardia, fatigue.
RESPIRATORY: Denies sob. Cough.
GASTROINTESTINAL: Denies abdominal pain
GENITOURINARY: Denies polyuria, incontinence, urgency, or frequency
NEUROLOGICAL: Denies visual or auditory hallucinations
MUSCULOSKELETAL: Complaints of pain in feet from failed surgeries
HEMATOLOGIC: No anemia, bleeding.
ENDOCRINOLOGIC: No polyuria or polydipsia
Reproductive Hx: Para 5 Grava 5
Diagnostic results: Anxiety assessment GAD-7; Depression Assessment (Hamilton
Rating Scale for Depression), PTSD Assessment
Physical assessment-N/A
Mental status exam-Patti is a 40-year-old Iranian-born female. Divorced from abusive
husband. Left Iran with a medical visa and decided to stay in US without her husband. She is
here for individual psychotherapy. She reports feeling lonely, hopeless, depressed and sad. She
is Disabled and not able to work. She lives in constant pain. She has 5 children who are not
supportive of her.
She is appropriately dressed and well groomed, answering questions appropriately.
Speech is clear and coherent. She is awake alert and orientated x4. Her speech is clear and
general behavior is acceptable, motor and speech activity within normal limits, mood is hopeless
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and affect is sad. Patti is upset because the children are not helping her and her culture children
take care of parents. Her daughter Sherleen feels she is still young enough to take care of
herself, and she wants to discover her own life.
Differential Diagnoses:
1. MDD-Depression (major depressive disorder) is a typical and severe medical illness
that can affect a person negatively on how you feel, think and act. This is a treatable condition.
Depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed. It
can lead to a variety of emotional and physical problems and can decrease your ability to
function at work and at home (Torres, 2020). Depression is a psychiatric disorder, with an
estimated lifetime prevalence of 10% in the general population. It can reach as high as 20%
according to DSM 5. Diagnosis MDD requires five or more symptoms in a 2-week period. One
symptom is depressed mood or anhedonia. Second symptom is appetite changes, sleep
difficulties, psychomotor agitation or retardation, fatigue or loss of energy, diminish
concentration, feeling worthless or excessive guilt and sucicalilty (Tolentino & Schmidt, 2018).
2. Adjustment Disorder-This describes a maladaptive emotional/behavior response to
identifiable psychosocial stressor (O’Donnell et al., 2019). Patti's children are not helping her,
and she is not adjusting to the new American culture. There are difficulties adjusting to being
disabled and stress of not being independent. The stress reactions that are out of step with
socially or culturally expected reactions to the stressor which cause marked distress and
impairment in daily functioning. There is a clear criterion for what constitutes a traumatic event,
PTSD or ASD have a clear traumatic event. Adjustment disorder criteria doesn't specify any
requirement for a specific stressor (O’Donnell et al., 2019).
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3. GAD General Anxiety Disorder- according to DSM-5 excessive anxiety and worry
(apprehensive expectation), occurring more days than not for at least 6 months, about a number
of events or activities (“Anxiety and Dsm-5,” 2015). The DSM-5 chapter on anxiety disorders
now reflects a developmental approach, with disorders sequenced according to the usual age at
onset. In addition, a 6-month period is now expanded for all ages for these disorders, including
specific phobia and social anxiety disorder. Currently, panic attacks can now be listed as a
specifier that is applicable to all DSM-5 disorders, not just anxiety disorders. Panic disorder and
agoraphobia are now unlinked in DSM-5, each with separate criteria. Separation anxiety disorder
and selective mutism are classified as anxiety disorders (“Anxiety and Dsm-5,” 2015). Patti has
extreme anxiety related to her children helping her at home. She wants her daughter to sleep
over and stay with her. GAD is the most frequent disorder in primary care. It is 8% of
population and statistically associated with age and gender. Comorbidity are depression and
somatization. GAD impairs daily life and work (Jordan et al., 2017).
My thinking process leads me to these diagnosis first diagnosis of MDD. She is
hopeless, loneliness and sad because of her disability and pain. Second choice was AD. She is
unable to accept her children's choice of being American lifestyle; she doesn't like the way her
daughter dresses, and she is upset she wants to start her own life. Culturally she expects her to
stay with her and take care of her. She is not able to accept her actions. Finally, GAD is closely
related to MDD. She has constant worry about what she is not getting from her children and
continue to argue with her daughter about her absence in the home.
Case formulation &Treatment plan that includes psychotherapy interventions-
(PHQ)-9 GAD-7, The PSS-SR questionnaire; Continue therapeutic communication use
reflective assessment with patient. Guided communication to help patient understand children
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are culturally following western culture. Continue to have family and individual psychotherapy.
Start Weight Watchers, exercise regimen, Refer to PMHNP for medication management. Start
Zoloft 25mg PO QD. Trazadone 25mg PO HS. Hydroxyzine 25mg PO TID PRN. Re-eval 2
weeks. Client has emergency numbers: Emergency Services 911, the Client's Crisis Line 1-800-
777-1111. Client instructed going to the nearest ER or call 911 if they become actively suicidal
and/or homicidal
Reflection-Understand other cultures is important to help patients. Patti was from
another culture, and she mentioned her daughter would be possibly killed for some of her
clothes choices; this alarmed me. As western culture we don't realize how different other
cultures and religions are. Patti struggles with the change of culture with her children. She
cannot adjust to new culture and being disabled. In my reflection and can be insensitive to other
people culture. I can improve to be more beneficial to my patents.
Genogram
211518
23
24
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References
Anxiety and dsm-5. (2015). Anxiety, 17(3), 245–246. Retrieved December 12, 2021, from
https://doi.org/10.31887/dcns.2015.17.3/dkupfer
Jordan, P., Shedden-Mora, M. C., & Löwe, B. (2017). Psychometric analysis of the generalized
anxiety disorder scale (gad-7) in primary care using modern item response theory. PLOS
ONE, 12(8), e0182162. Retrieved December 12, 2021, from
https://doi.org/10.1371/journal.pone.0182162
Mother and Daughter: A Cultural Tale. . [Video/DVD] Masterswork Productions.
https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale [Video].
(2003).
O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment
disorder: Current developments and future directions. International Journal of
Environmental Research and Public Health, 16(14), 2537. Retrieved December 12, 2021,
from https://doi.org/10.3390/ijerph16142537
Tolentino, J. C., & Schmidt, S. L. (2018). Dsm-5 criteria and depression severity: Implications
for clinical practice. Frontiers in Psychiatry, 9. Retrieved December 12, 2021, from
https://doi.org/10.3389/fpsyt.2018.00450
Torres, F., MD. (2020, October 1). What Is Depression? American Psychiatric Association..
Retrieved December 12, 2021, from https://www.psychiatry.org/patients-
families/depression/what-is-depression
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